Ob-Gyn Coding Alert

Question: If the ob-gyn 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?

Nevada Subscriber

Answer: No, you cannot code based on time with just the documentation you have mentioned. Medical decision making does not qualify as one of the criteria for choosing time.

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, and this fact must be noted in the documentation.

How it works: According to the CPT^® manual, you can use the code closest to the documented time. If coding by time, pick the closest typical time, noting that typical time for E/M services is threshold time, not incremental time. That advice echoes previous AMA information. For instance, the September 2013 CPT^® Assistant stated, “ When coding on the basis of time, the typical times in E/M code descriptors should be viewed as thresholds.”

Your documented time must equal or exceed the average time given to bill that level. For a 20 minute visit which was dominated by  medically necessary counseling, per CPT^® you could report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ... Typically spend 15 minutes face-to-face with the patient and/or family), rather than 99214 (…typical time of 25 minutes…) because the total time of the encounter did not reach the threshold of 25 minutes associated with 99214

In 2014, the CPT^® guidelines for use of time were amended to include the following statements.

“…standards shall apply to time measurement, unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary

When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used. See also the Evaluation and Management (E/M) Services Guidelines.”

The timed codes they are referring to are ones that only are reported on time, not E/M codes which can only be reported on time when counseling and/or coordination of care dominates the visit.

Keep in mind: CPT^® notes that “this 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.”

Medicare payers have always considered the times indicated in CPT^®’s code descriptors to represent minimums. The practice that does quite a bit of counseling services can increase the level of services billed but also runs the risk of a payer audit based on a greater percentage of higher-level services.

Also keep in mind that the note must clearly reflect the nature and complexity of the counseling involved. A notation that “patient was counseled regarding surgical options, all questions answered” would not be sufficient under any circumstances to support counseling time as the controlling factor for the visit, even if the time spent is correctly stated as a percentage of total time.