EM Coding Alert

Don’t get caught out watching the clock.

You may think you have a handle on office/outpatient evaluation and management (E/M) coding. But is that really the case? In her Regional HEALTHCON 2024 presentation, “E/M Coding: An Auditor’s Perspective,” Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor, physician coding auditor/educator consultant for medKoder in Mandeville, Louisiana, offered a view of E/M coding from an auditor’s standpoint, and what she had to say may surprise you.

In the first part of this series, you’ll find some of the things Clements noted when you want to determine an E/M service level by time. They might give you pause the next time you code one of your otolaryngologist’s patient encounters.

Know Your Time Thresholds

First, if you are determining an E/M service level by time, it’s important to remember that any E/M encounter “must meet the minimum time ... there’s no halfway mark. Even one minute short doesn’t get you to that level,” according to Clements. This echoes CPT^® E/M guidelines that tell you “each service that may be reported using time for code level selection has a required time threshold. The concept of attaining a mid-point between levels does not apply.”

The same is true for prolonged services reported with +99417 (Prolonged outpatient evaluation and management service(s) time … each 15 minutes of total time …) and +99418 (Prolonged inpatient or observation evaluation and management service(s) time … each 15 minutes of total time …). “You have to have the full 15 minutes to report one quantity of that … if you just go over 14 minutes, that one minute short is going to cost you for being able to code for that,” Clements cautioned.

Know How to Count Prolonged Service for Different Payers

Different payers count time for prolonged services differently, which can be the source of great confusion among coders.

Private payers use +99417 with the two highest levels of new and established patient E/M services. So, for a new patient office/outpatient E/M service lasting 60-74 minutes, you will use 99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60 minutes must be met or exceeded). Once the encounter reaches the 75-minute threshold, you can then go ahead and add one unit of +99417 to 99205; at 90 minutes, you can add a second unit of +99417, and so on.

You can use a similar calculation for established patients. You would use 99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40 minutes must be met or exceeded) for an established patient office/outpatient E/M service lasting 40-54 minutes, adding one unit of +99417 for a service lasting for 55 minutes, a second unit of +99417 for services lasting 70 minutes, and so on.

Medicare and payers following Medicare guidelines calculate prolonged service time differently by beginning their calculations beyond the maximum time required for the primary E/M service. That means you would not start adding units of prolonged service until the 99205 service reaches the 89-minute threshold or the 99215 service reaches the 69-minute threshold; you would add a second unit when the 99205 service reaches the 104-minute threshold or the 99215 service reaches the 84-minute threshold, and so on.

That’s why Medicare and payers following Medicare guidelines do not use +99417 to report prolonged services. Instead, they require HCPCS Level II code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes … (list separately in addition to cpt codes 99205, 99215, 99483 for office or other outpatient evaluation and management services) … (do not report g2212 for any time unit less than 15 minutes)).

Know What to Count

Clements then noted that time includes “basically anything on that date of service that you are not billing for separately,” including the following:

• Preparing to see the patient (e.g. review of tests)
• Obtaining and/or receiving separately obtained history
• Performing medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals
• Documenting clinical information in the electronic health record (EHR)
• Independently interpreting results
• Care coordination

Importantly, “when you have a situation where multiple providers are seeing a patient in a day, those providers of the same group or specialty can be coded as if they were one person … those times can be combined for a total time. However, you can’t sum together when two or more providers are seeing the patient together and their time overlaps,” Clements cautioned.

And Know What Doesn’t Count

Other things that cannot count toward time include any prep work, documentation, or test result interpretation the provider performs either before or after the date of service. Similarly, you cannot count time spent on other separately reportable services, travel time, or time spent teaching. Additionally, provider time spent incident-to a noncredentialled employee such as a medical assistant, a registered nurse (RN), or a licensed practical nurse (LPN) cannot be counted. But keep in mind that if your provider is working with a resident, and they are both working on patient management, that time can count, according to Clements. Just make sure the provider’s presence and contributions are documented.

Also, while provider documentation time can be counted, a provider who is a significantly slow documenter would need to be adjusted for how long it would take for normal documentation speed.

Understand This Audit Risk

Suppose Medicare comes in and it audits 50 patients that have all been reported as 99214 (Office or other outpatient visit for the evaluation and management of an established patient … 30 minutes must be met or exceeded). Every record notes that the provider has spent exactly 30 minutes on each patient. “That looks a little fishy, because everybody has a different history, everybody has a different disease, everybody has a different prognosis, and different treatment options. This looks suspicious from an insurance point of view,” Clements noted.

Also, keep in mind that if you use time for every patient, payers will look at that time and multiply it by the number of patients seen to come out with the total time the provider spent seeing patients in the office. Often, this can add up to times that are unrealistic and unbelievable. Even though it doesn’t count non-face-to-time, an EHR tracks time spent on a patient encounter and can show conflicting data when compared to time-based claims submitted to third-party payers.

Next month: In part two, we’ll look at coding E/M services using medical decision making (MDM) from an auditor’s perspective!

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC