Pulmonology Coding Alert

Question: One of our pulmonologists started billing based on time for more visits than usual, and when we asked why, he said it’s because the electronic health record now records the time spent and he’s billing based on that. Is this allowed?

Codify Subscriber

Answer: The answer depends on how he’s using the information he records, and whether it’s accurate.

One of the perks of electronic health records is that they typically record the date and time that you input information. In fact, many EHRs record a summary of the time spent on the record at the bottom of each visit’s documentation and give a total, such as “Total time: 26 minutes, 15 seconds.”

Practices have reported that they have used this time calculation to select an E/M code. For example, if the EHR says that the time spent is 25 minutes, these practices are automatically reporting 99214 for the visits, using the rationale that CPT^® and Medicare guidelines allow you to code E/M services based on time.

Reality:  The key to billing based on time is that counseling and/or coordination of care must dominate the visit. Therefore, you can only select an E/M code using time as the controlling factor if you meet the rules, and an EHR’s notation of time spent in the record will not meet those guidelines. Instead, your documentation must contain the following three elements:

• Notation of the total time spent on the encounter.
• Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/care coordination.
• The reason for/topic of the counseling/care coordination.

For outpatient services, this total time considered must be face-to-face time between the patient and the billing provider. Inpatient time allows you to count the face-to-face time as well as the floor time spent involving indirect care of the patient (e.g., reviewing data, speaking with the nurse about overnight events, etc.)

For example, the following statements would allow billing based on time alone: “25 minute office visit with 20 minutes spent on counseling about medication options for recurrent bronchitis” or “Total encounter: 55 minutes with more than 50 percent spent on coordination of care for patient’s worsening COPD.”

In an EHR, you may not know where to put such a statement, but most of these systems will have a radio button somewhere in the software that you can press to create a comment box. As long as you enter your statement about time as indicated above anywhere in the record, you can code based on time, but simply stating the total time you spent-- or letting the EHR calculate it for you-- is not adequate.