EM Coding Alert

Question: Our gastroenterologist saw a colitis patient in the hospital and did not maintain thorough notes about the history or exam. However, he documented that he spent 36 minutes on the encounter and discussed treatment options with the family. The visit does not constitute critical care, so how can we bill this service?

Georgia Subscriber

Answer: You may be able to bill this encounter based on time, since the physician noted the time spent and what was discussed. However, you must ensure that the documentation is clear about how much of the visit was spent in counseling/care coordination — both total encounter time and time spent counseling/coordinating care must be stated.

Background: Because 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components…) is the highest level of subsequent hospital care, documentation typically requires two of these three criteria: A detailed history, detailed exam, and/or high complexity medical decision making (MDM). However, you can also report 99233 based on time if you meet the documentation requirements. CPT^® assigns a 35-minute time threshold to this code. Although many coders think of time-based E/M coding only as an outpatient strategy, it’s perfectly acceptable to use time as your overarching code selection criteria in the inpatient setting, if you meet the guidelines.

This means ensuring the following three factors are documented in the hospital record if you select 99233 based on time:

1. The total time spent during the inpatient encounter (which should be at least 35 minutes for 99233)
2. The time spent counseling/coordinating care (which must exceed 50 percent of the total visit time)
3. A description or summary of the counseling/ coordination of care provided.

Keep in mind that the total time for an inpatient is considered as the face-to-face time plus the unit/floor time spent in care directly related to the patient.

For instance, the documentation would say something like: “Total visit time was 35 minutes; 20 minutes of that visit was spent counseling the patient and her husband about potential treatment options and management techniques for colitis, as well as prognosis. Answered multiple questions and provided them with educational information.”

Although this question indicates that the gastroenterologist documented the total time spent and what was discussed, there’s no indication that the physician spent at least half of that time on counseling/coordinating care. In these situations, you may not be able to bill based on time unless you have a record of how much time was spent counseling/coordinating care.