You Be the Coder:
Office Visit Based on Time
Published on Mon Apr 01, 2002
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: Examination of a new patient took 60 minutes, a lot longer than usual. Coordination of care wasn't mentioned in the chart. Based on the history, examination and medical decision-making, only a 99203 may be billed. Can we use time as the main factor to boost the visit to a level five?
Maryland Subscriber
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Answer: To calculate the level of a patient visit based on time, more than 50 percent of the time spent with the patient must be counseling or coordination of care.
CPT states in its E/M guidelines that "When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. 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 (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record."
In this case, the extensive new patient examination (not counseling or coordination of care) took more than 30 minutes (the time limit mentioned in 99203 guidelines). Therefore, it would be inappropriate to bill a higher-level E/M based on time. Instead, the otolaryngologist must look to the prolonged service codes in the E/M section to obtain additional compensation.
There is some confusion about using these codes with lower-level E/M services. Modifier -21 (Prolonged evaluation and management services), a little-used and rarely paid modifier, may be appended only to the highest-level E/M service in a category. This is not the case for the prolonged services codes, which have all but supplanted -21 as a method for reporting additional time during an E/M service.
In this case, +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) should be reported because the otolaryngologist spent 30 minutes of additional time with the patient beyond the reference time for the E/M service documented.
At least 30 minutes must be documented for prolonged service time of 60 minutes. Because the reference time for 99203 is 30 minutes and the otolaryngologist spent a total of 60 minutes with the patient, +99354 may be billed in addition to 99203, assuming the 60 minutes are documented. If more than 75 minutes had been spent with the patient, code +99355 could also have been billed.
Note: Some private payers do not recognize and will not reimburse prolonged services.
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