Otolaryngology Coding Alert

Steer clear of these four auditor red flags when coding time.

A surefire way to maximize reimbursement and reduce the stress associated with audits is to strengthen your understanding of how to properly code evaluation and management (E/M) services. One concept many coders are trying to get up to speed on is determining the level of an E/M encounter using time.

If you find yourself scratching your head as you work to become more well-versed in the 2021 updates to the CPT^® codes for office and outpatient visits, now is the time to cut through the confusion, as these concepts now apply to level determination for an even wider range of E/M services.

Recognize Which Activities Count Toward Time

Using total time rather than counseling and/or coordination of care to level an E/M encounter is a relatively new concept, so let’s review the basics. Per the 2023 CPT^® guidelines, the full list of activities that you can use to count time includes:

• Preparing to see the patient (e.g., review of tests);
• Obtaining and/or reviewing separately obtained history;
• Performing a medically appropriate examination and/or evaluation;
• Counseling and educating the patient/family/caregiver;
• Ordering medications, tests, or procedures;
• Referring and communicating with other healthcare professionals (when not separately reported);
• Documenting clinical information in the electronic or other health record;
• Independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver; and
• Care coordination (not separately reported).

“One of the most common misconceptions on reporting an E/M based on time is that a provider is required to document the time spent on each specific task associated with the visit,” says Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts. Instead, the provider needs to document the total time personally spent on the above-listed activities on the date of the encounter.

There are some misconceptions floating around that can wreak auditing havoc; however, Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, cleared many of them up in “Risk Associated with Coding Time,” her presentation at HEALTHCON Regional 2022.

Here are four issues to put on your radar, as auditors see them as time-related red flags.

Red Flag 1: Rounding Up Total Time

Rounding up will absolutely raise red flags to an auditor. Rounding up a few minutes on each encounter — turning 16 minutes into 20, or 25 into 30 — may not seem like a big deal, but it can be. Plus, “you don’t want the time to look the same for every single patient,” said Jimenez.

Think about it this way: Rounding up time for every patient could make it appear as though your physicians spent hours longer at the clinic than they really did. Inflating time, whether intentional or not, is not best practice. In fact, compliance enforcement could consider it abuse or fraud, both serious and costly.

Red Flag 2: Including Ancillary Staff Time

Make sure to review and apply the 2023 CPT^® E/M guidelines, which state that if a physician and other qualified healthcare professional (QHP) — such as a nurse practitioner (NP) or physician assistant (PA) — shared or split the time assessing and managing the patient, that time is summed to define total time on the date of the encounter. However, only distinct time should be summed for shared or split visits (i.e., when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).

For example, if a patient sees an NP for a follow-up, that NP will start evaluating any new patient complaints. The patient may then consult with your otolaryngologist about the problem and finalize a treatment plan. “The time they spent in the room together is going to count only once. So, if the nurse practitioner spent 10 minutes with the patient, then invites the physician in and they spend 15 more minutes together, it’s going to be a total of 25,” said Jimenez.

Tip: Total time does not include time for activities the clinical staff normally performs or the time it takes to perform other services that are reported separately.

Red Flag 3: Not Documenting Services Performed Outside the Visit

Documenting time correctly is not only best practice — it often counts in favor of the physician. “The AMA defines time for E/M coding as the total time (based on minutes) the provider spends on the date of service during which a provider personally rendered services related to the patient’s care, even if the times are not consecutive,” explains Walaszek. But sometimes physicians forget to document all their time.

As long as those forgotten services, such as reviewing labs after the encounter, are accounted for in the record and performed on the date of the encounter, you can justify that time if an auditor questions it. Be careful, though, not to double-count that time if the physician and NP spend time discussing a problem outside of the room after the encounter.

Red Flag 4: Botching the Billing of Other Services

Some services are billable but don’t get counted toward total time when they should, as Red Flag 3 explained. This could be the case when your provider documents how many minutes they spent with the patient, but they don’t include the time spent preparing to see them. An oversight like this is common for physicians who are still accustomed to documenting in-office visits based only on face-to-face time.

On the other side, sometimes practices mistakenly count services twice. For example, many minor surgeries have the E/M built into the CPT^® code payment for the procedure, so counting that pre-procedural evaluation time toward time used to report an E/M code would be double counting and result in the physician getting paid twice. Pay close attention to which procedure codes include E/M to avoid making that mistake. Also, pay close attention to the documentation. “If the physician is performing other billable services, add a note that says, ‘total time is 20 minutes excluding other billable services,’ so that in an audit, there is no question,” said Jimenez.

Final Thoughts on Avoiding Time-Based Leveling Snafus

Using time to level an encounter is perfectly legitimate — and it’s often in the physician’s best interest to code this way, especially when they spend enough time to warrant billing for prolonged services. The documentation must be precise, though, to justify the time spent. When auditors perform time-based

audits, “they will look at your schedule for the day and see how much time was worked, then total up all your visits. If you coded based on time and those hours add up to 20, but the actual hours worked was only 10, that doesn’t add up,” said Jimenez.

Fixing these issues before they become bigger issues might be a matter of more precise time reporting. Rounding up, forgetting to document same-day non-face-to-face time, and misrepresenting other billable services will all lead to inconsistencies during an audit. The best thing to do is study the patterns of the practice to see if there are any anomalies. As always, be sure to keep an open line of communication between your coding department and your physicians.