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 this year's CPT manual, you can use the code closest to the documented time. "If coding by time, pick the closest typical time," said Peter Hollmann, MD, during the "E/M, Vaccines, and Time-Based Codes" session at the CPT and RBRVS 2011 Annual Symposium in Chicago this past fall.

That advice echoes previous AMA information. For instance, the August 2004 CPT Assistant stated, "In selecting time, the physician must have spent a time closest to the code selected."

Your documented time must equal or exceed the average time given to bill that level. 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).

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."

Remember that although the AMA, via CPT Assistant, directs you to code based on the "closest" time, Medicare payers have always considered the times indicated in CPT's code descriptors to represent minimums. Under those regulations for the above example of 35 minutes of face to face time, 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). Many commercial payers also have adopted this interpretation of rounding down, not up. In rounding up, 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.