General Surgery Coding Alert

CPT® 2023:

Sidestep 4 Pitfalls When Reporting E/M by Time

Published on Fri Dec 16, 2022

Make sure to document non-face-to-face work.

Now that CPT^® has revised the list of evaluation and management (E/M) services that you can report based on time for 2023, it’s more important than ever that you avert some common reporting errors that could result in returned claims or sacrificed pay.

Help is here: To avoid misconceptions about the updated guidelines, look at these insights from Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, from her recent HEALTHCON Regional 2022 presentation, “Risk Associated with Coding Time.”

Clarify Which Activities Count Toward Time

Per the 2023 CPT^® guidelines, the full list of activities that you can include in total time includes:

“Preparing to see the patient (eg, review of tests)
“Obtaining and/or reviewing separately obtained history
“Performing a medically appropriate examination and/or evaluation
“Counseling and educating the patient/family/caregiver
“Ordering medications, tests, or procedures
“Referring and communicating with other health care professionals (not separately reported)
“Documenting clinical information in the electronic or other health record
“Independently interpreting results (not separately reported) and communicating results to the patient/family/ caregiver
“Care coordination (not separately reported)”

“One of the most common misconceptions on reporting an E/M based on time is that a provider is required to document the time spent on each specific task associated with the visit,” says Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts. However, the provider needs to instead document the total time personally spent on the above-listed activities on the date of the encounter.

Avoid 4 Traps That Auditors See as Red Flags

Getting used to billing more E/M services based on time might take some practice. Read on to see some common errors you should avoid to make the best use of time-based reporting.

Pitfall 1— rounding up: Rounding up a few minutes might not seem like a big deal for an encounter — turning 16 minutes into 20, or 25 into 30. It is easy for your provider to not pay close attention to their watch. “That’s a little difficult, and I understand there’s some frustration with that, but you don’t want the time to look the same for every single patient,” said Jimenez. Think about it this way: when physicians round up on every patient, it has a dramatic effect by the end of the day. Adding an extra five minutes to each patient could end up looking like each physician spent hours longer at the clinic than they really did. Inflating time, whether intentional or not, is something practices should avoid.

Pitfall 2 — counting others’ time: Total E/M time does not include time for activities the clinical staff normally performs. Also be sure to review and apply the CPT^® guidelines for a shared or split visit. For example, if a patient comes in for a follow-up and sees a nurse practitioner (NP), that NP is going to start to evaluate any new patient complaints. Then the patient would likely consult with your provider about the problem and a new treatment plan. “The time they spent in the room together is going to count only once. So, if the nurse practitioner spent 10 minutes with the patient, then invites the physician in and they spend 15 more minutes together, it’s going to be a total of 25,” said Jimenez.

Pitfall 3 — neglecting services: Don’t miss the chance to legitimately report higher level services for your providers. “The AMA defines time for E/M coding as the total time (based on minutes) the provider spends on the date of service during which a provider personally renders services related to the patient’s care, even if the times are not consecutive,” explains Walaszek.

But sometimes physicians forget to document all of their time. For instance, providers may forget to include the time spent preparing to see the patient because they are still accustomed to documenting visits based on face-to-face time. If the medical record accounts for services performed on the same day outside the time with the patient, such as reviewing labs, you can bill for that time and justify it if an auditor questions it.

Pitfall 4 — double counting services: The flip side of pitfall 3 is adding time spent on a different billable service on the same date to the E/M time. For example, the E/M is built into the CPT^® code for many minor surgeries, so carving out time spent on that service would result in the physician getting paid twice. Pay close attention to which procedure codes include the E/M, and you’ll be sure to not make that mistake. Also, pay close attention to the documentation. “If the physician is performing other billable services, add a note that says, ‘total time is 20 minutes excluding other billable services,’ so that in an audit there is no question,” said Jimenez.

Takeaway: Be Confident About Time-Based Leveling

Using time to level an encounter is perfectly legitimate — and it’s often in the physician’s best interest to code this way. The documentation has to be precise, though, to justify the time spent. When auditors perform time-based audits, “they will look at your schedule for the day and see how much time was worked, then total up all your visits. If you coded based on time and those hours add up to 20, but the actual hours worked was only 10, that doesn’t add up,” said Jimenez.

Fixing these issues before they become bigger issues might be a matter of more precise time reporting. Rounding up, forgetting to document same-day out-of-office time, and misrepresenting other billable services will all lead to inconsistencies during an audit. The best thing to do is study the patterns of the practice and see if there are any anomalies. As always, be sure to keep an open line of communication between your coding department and your physicians to identify and resolve issues.