Neurology & Pain Management Coding Alert

Question: As a new coder, I am still a little confused by the times listed in the descriptors for evaluation and management (E/M) services 99201-99215. Are they average times, or are they the total amount of time a provider can spend counseling a patient. For example, 99214 states "Typically, 25 minutes are spent face-to-face with the patient and/or family." Does that mean the provider has to spend exactly 25 minutes with the patient or family, or is the time just an estimate?

Florida Subscriber

Answer: CPT^® guidelines state that "specific times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances."

The key term, though, related to time in 99201-99215 is "face-to-face." You can only count the amount of time the physician spends with the patient/family in counseling, examination, history-taking or decision-making. Time the provider spends reviewing the patient's medical records before the encounter, or documenting the encounter afterward, for example, do not count toward this typical time, and neither does time the patient spends with nurses, assistants, or other members of your practice's staff.

What often confuses new coders is when time becomes significant in choosing the correct E/M code for the encounter. Per CPT^®, when counseling and/or coordination of care are more than 50 percent of the encounter with the patient and/or family (e.g., face-to-face time in the office or other outpatient setting), then time rather than other factors (such as the examination, history, or type of decision making) is considered the key or controlling factor to qualify for a particular level of E/M services.

Good advice: When coding E/M levels on the basis of time, view the typical times in E/M code descriptors as thresholds. For instance, if a physician spends more than half of a 20-minute established patient office visit in counseling/coordination of care, and chooses to code on the basis of time, the physician should select code 99213 (Office or other outpatient visit for the evaluation and management of an established patient ... Typically, 15 minutes are spent face-to-face with the patient and/or family) rather than 99214 (... Typically, 25 minutes), because the total time of the encounter did not reach the threshold of 25 minutes associated with 99214.

To choose 99214, then, the physician would have to spend at least 25 minutes face-to-face with the patient and/or family, and more than 13 minutes would have to be spent counseling or coordinating the patient's care. But no matter which E/M level you choose, the extent of the counseling and/or coordination of care must be documented in the medical record.