EM Coding Alert

Question: If I am billing an E/M encounter by time, does documentation for the E/M elements have to be in the record, or can the E/M level be determined solely on the provider’s documentation of the time spent in counseling with the patient?

Arkansas Subscriber

Answer: Most coders are trained to look in the record for the elements — the history, exam, and medical decision making (MDM) — then compare the level of E/M that they create with the time the provider spends in counseling. If, as most often happens, the counseling time leads to a higher-level E/M, then coders will choose that way to determine the E/M level.

However, the elements do not need to be documented in order for you to code based on time. Consider a scenario where the parents of an 8-year-old patient present in the office to discuss their child’s bedwetting, but they do not want to discuss this issue in front of their son. Since the patient is not present, there will not be an exam, but the pediatrician may well take a very brief problem-focused history and exercise straightforward MDM.

In this scenario, the provider will probably counsel the parents on what could cause this issue and what type of treatment could be used. So, even though you may have a 99212 (Office or other outpatient visit for the evaluation and management of an established patient …. Typically, 10 minutes are spent face-to-face with the patient and/or family) visit based on the problem-focused history and straightforward MDM, you would want to bill the E/M code (using the child’s name and ID) based on counseling and coordination of care using time as the key.

In this scenario, as with any determination of E/M levels, what is more important than the E/M elements is medical necessity. So, providing your records contain some form of statement about what occurred during the visit and why, then you can justify billing by time without any documentation of the elements. As an example, a statement such as “Today’s visit lasted a total of 10 minutes, with greater than 50 percent in counseling concerning the causes of enuresis and treatments with the parents” would be sufficient to justify billing 99212.