Wiki Coding Based on Time

[Shelley Gillespie]

A provider codes a subsequent hospital visit as a 99233. The encounter is audited as a 99232 based on the elements in the history, exam, mdm. However, the provider has noted that greater than 45 minutes was spent coordinating care for the patient, with details of the discussion. The provider did not document the total time of the encounter. Is it appropriate to code this encounter based on time, or should the encounter be coded on the elements in the history, exam, mdm?

 

[MikeEnos]

What you really need to have is documentation that the counseling DOMINATED the encounter. In other words, it's not good enough to just state the counseling time - you need to demonstrate that greater than 50% of the time was spent counseling.

For example, here's the times for Subsequent Hospital Care codes
99231 - 15 mins
99232 - 25 mins
99233 - 35 mins

If the provider documented that 25 minutes of the 60 minute encounter was spent counseling, then the counseling did not dominate the encounter. Even though 25 minutes of counseling alone is good enough to bill it as a level 2 based on time, since the counseling did not dominate the encounter it cannot be used as the controlling factor when determining the level of care.

That's my interpretation, some carriers may have their own rulings on this.

What you may want to do is bill the level of care based on the key components (history, exam, mdm) THEN bill the additional ADD-ON code for prolonged services because of the lengthy extra time spent counseling and coordinating care. This will achieve maximum reimbursement (and be more accurate in my opinion) compared to just billing a level 3 progress note.