Orthopedic Coding Alert

Question: One of our providers wants to report 99203, using time to meet the level requirements for the code. The documentation the provider used stated that “25 or more minutes were spent face-to-face with the patient, and much of the encounter was spent counseling the patient on their current condition.”

Is this sufficient documentation for the 99203? Specifically, does the total time have to be at least 30 minutes in this encounter to justify a level-three new patient evaluation and management (E/M) code?

Nevada Subscriber

Answer: To bill an E/M based on time, you should first pick the code closest to the amount of time associated with it. So, if your provider documented they had spent exactly 26 minutes in total time with the patient, you would pick 99203 (Office or other outpatient visit for the evaluation and management of a new patient . Typically, 30 minutes are spent face-to-face with the patient and/or family) rather than 99202 (… Typically, 20 minutes …), as the 26 minutes is closer to the 30 minutes of 99203 than it is to the 20 minutes of 99202 (… An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …). 

Then, you need to document that the counseling component of the encounter lasted “more than 50 percent” of that time, or more than 16 minutes in the case of 99203. The provider must also document the nature of the counseling performed.

In your description of the encounter, there is no indication that these criteria have been met. First, documenting “25 or more minutes” is not precise enough for documentation purposes. Similarly, the counseling component must be documented as “more than 50 percent” of that time, or more than 16 minutes in this case. Documenting “much of the encounter” is, again, not precise enough. Finally, you do not say whether the provider documented the nature of the counseling provided to the patient.

Consequently, you must work with your provider to accurately document this service if you still want to code it based on time. Alternately, you may find that the note has enough documentation to provide medical necessity, enabling you to count the E/M components of a detailed history, a detailed examination, and low-complexity medical decision making (MDM) to justify a level-three new patient E/M.