General Surgery Coding Alert

Question: If the physician documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min," can I choose the E/M code based on time alone?

Texas Subscriber

Answer: No, you cannot code based on time with just the documentation you have mentioned.

Here's why: You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care.

How it works: According to the 2011 CPT® manual, you can select the code that represents the time "closest to the documented time." That advice echoes previous AMA information. For instance, the August 2004 CPT® Assistant states, "In selecting time, the physician must have spent a time closest to the code selected."

For example: For a 35-minute visit spent on a medically necessary counseling-dominated visit, per CPT® you could report 99215 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 40 minutes face-to-face with the patient and/or family).

CMS difference: Remember that although the AMA directs you to code based on the "closest" time, most Medicare payers have always considered the times indicated in CPT® code descriptors to represent minimums. Under those regulations, the physician would select the lower code (for instance 99214, ... physician typically spends 25 minutes face-to-face with the patient and/or family ...) unless the time was greater than or equal to the higher-level code's required time (such as 40 minutes for 99215).

Counseling tip: CPT® notes that counseling time "includes time spent with parties who have assumed responsibility for the care of the patient or decision-making, whether or not they are family members (for example, foster parents, person acting in loco parentis, legal guardian." But Medicare won't pay for counseling services unless the time was face-to-face with the patient (at least partially for inpatients) -- not a decision maker for the patient.