Pulmonology Coding Alert

Make sure you don’t bill a service twice.

Using total time to level an evaluation and management (E/M) encounter has continued to confuse coders since the 2021 updates to the CPT^® Office and Other Outpatient Services were implemented. Now, hospital and inpatient E/M services have received these E/M rules, too.

Luckily, Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, cleared up many misconceptions that could wreak auditing havoc during her “Risk Associated with Coding Time” session at AAPC’s HEALTHCON Regional 2022 in Denver.

Remember Which Activities Count Toward Time

Per the 2023 CPT^® guidelines, the full list of activities that you can use to count time includes:

• “Preparing to see the patient (eg, 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 health care 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
• 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. The provider needs to instead document the total time personally spent on the above-listed activities on the date of the encounter.

Here are three issues that auditors see as time-related red flags.

Red Flag 1: Coders Rounding Up Total Time

Rounding up E/M total time will surely raise red flags to an auditor. It might not seem like a big deal to round up a few minutes on each encounter, turning 16 minutes into 20, or 25 into 30. It is easy for your provider to not pay close attention to their watch. “That’s a little difficult, and I understand there’s some frustration with that, but you don’t want the time to look the same for every single patient,” said Jimenez. Think about it this way: when physicians round up on every patient, it has a dramatic effect by the end of the day. Adding an extra 5 minutes to each patient could end up looking like each physician spent hours longer at the clinic than they really did. Inflating time, whether intentional or not, is something practices should avoid.

Note: Total time does not include time for activities the clinical staff normally performs. Also be sure to review and apply the CPT^® guidelines for a shared or split visit. For example, if a patient comes in for a follow-up and sees a nurse practitioner (NP), that NP is going to start to evaluate any new patient complaints. Then the patient would likely consult with your provider about the problem and a new 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.

Red Flag 2: Forgetting to Document Services Performed Out of the Office

Documenting the 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. So, what’s sometimes happening is physicians are forgetting to document all their time.

If those forgotten services are accounted for in the record and performed on the date of the encounter (for example, reviewing labs after the encounter on the same date of service [DOS]), you can justify that time if an auditor questions it. As noted above though, be careful not to double-count time if the physician and a QHP (e.g., NP) spend time discussing a problem outside of the room after the encounter.

Red Flag 3: Reporting Other Billable Services Incorrectly

Some services are billable but physicians forget to count for all their time spent, as Red Flag 2 explained. This would 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. This is common for physicians who are still accustomed to documenting in-office visits based only on face-to-face time.

On the other hand, sometimes services get counted twice. For instance, for many pulmonary function tests (PFTs) like spirometry, the global CPT^® code for the procedure includes the review of the procedure’s data. If you counted the time the physician took to interpret the PFT’s data toward the total time used to report an E/M code, you would be double counting. This error would result in the physician getting paid twice for the same time. PFTs, such as 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation), are billed separately, and you cannot use the time spent performing the procedure or interpreting the results to calculate the total E/M time for the encounter.

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.

Takeaway: Confidently Use Time-Based Leveling

Using time to level an encounter is not only perfectly legitimate, it’s also often in the physician’s best interest to code this way. 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 to identify and resolve issues.