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adudms

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When coding by time, is the 50% rule for the entire time a patient is in the office, or just when having direct contact with medical personnel? Example - we do minor outpatient surgery. Every patient goes through a counsel session to discuss the surgery, review medical records, consent questions, concerns etc and make the final decision to proceed (these sessions last anywhere from 30 min to an hour or more) then meets the doctor for another session (about fifteen minutes), then has a final session at the end to discuss care, follow up, counselling etc (at least 30 minutes, sometimes more). The total time a patient is here can rum anywhere from 2-4 hrs, but a lot of that is waiting to go from step to step. If I code by time,I always come up with a higher code level than if I bill by 1995 guidelines. I want to justify the level of coding that accounts for all the time our doctor, nurses and counselors spend face to face with our patients but I also don't want to get in trouble if an audit is done.
 
Face-to-face time with the PROVIDER, not ancillary staff. To code based on time, more than 50% of the provider's time needs to be spent counseling and/or coordinating care.
 
If the patient is there for a scheduled procedure then the only billable item is the actual procedure. This includes all preoperative discussion as well as al postoperative. The medical necessity to perform the prodcedure, examination, and discussion with the patient has all been performed prior to scheduling the procedure.
 
Under CMS guidelines, you can only consider the face-to-face time between the physician and the patient. Commercial payers may have different guidelines for this though. This is from section 30.6.1 of the Medicare Claims Processing Manual, Chapter 12, which addresses E&M services:

"In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided."
 
January 2017 Healthcare Business Monthly "Details Matter for Time-based E/M Services"

You can access the Healthcare Business Monthly (January 2017 edition) through this AAPC website which should certainly answer your question. Submitted by Suzan Hauptman, MPM, CPC, CEMC, CEDC and John Verhovshek, MA, CPC, the article considers time as the key factor the E/M services.

"Typically, X minutes are spent face-to-face with the patient and/or family." refers specifically to time spent BY THE PROVIDER ONLY (not ancillary staff).

The Medicare Claims Processing Manual, chapter 12, section 30.6.1.C states: "...when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter...time is the key... the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim."

The authors of the article continue by stating that "The physician shouldn't limit the documentation to only the time and counseling information, but should also include information gathered from the history and examination elements, as well as MDM concerning ordered and reviewed test, co-morbid conditions, etc., to further substantiate the level of service and the time spent counseling" (Hauptman & Verhovshek, 2017).

I hope this information helps you in answering your question. Please refer to the January 2017 publication of AAPC's Healthcare Business Monthly for further details and additional information on this and other subjects!
 
adudms said:
When coding by time, is the 50% rule for the entire time a patient is in the office, or just when having direct contact with medical personnel? Example - we do minor outpatient surgery. Every patient goes through a counsel session to discuss the surgery, review medical records, consent questions, concerns etc and make the final decision to proceed (these sessions last anywhere from 30 min to an hour or more) then meets the doctor for another session (about fifteen minutes), then has a final session at the end to discuss care, follow up, counselling etc (at least 30 minutes, sometimes more). The total time a patient is here can rum anywhere from 2-4 hrs, but a lot of that is waiting to go from step to step. If I code by time,I always come up with a higher code level than if I bill by 1995 guidelines. I want to justify the level of coding that accounts for all the time our doctor, nurses and counselors spend face to face with our patients but I also don't want to get in trouble if an audit is done.
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So are you billing an E/M along with the minor outpatient surgery? Any counseling, reviewing of medical, questions answered regarding surgery, discussing following-up and all the stuff you mentioned would be part of the procedure itself, and shouldn't be billed separately. Doing that alone, may open you up to an audit.

An example of when it would be appropriate to bill based on time is if you had a physician who was seeing a patient who has a new diagnosis of diabetes. It takes the physician to 20 minutes to do his normal stuff (History, Exam, MDM)....however this patient has a lot of questions regarding this new diagnosis, and the physician spends an additional 25 minutes with this patient, the key part in all of this is that it is face-to-face with the physician...nurses, counselors, residents, assistants, none of those matter...only the billing physician's time...no one else's. The other important part is to look at the time spent on each part....20 minutes on the routine stuff, an additional 25 minutes counseling the patient. The TOTAL time spent is 45 minutes (99215 for return patient, 99204 for new)....of that 45 minutes OVER 50% of it was spent on counseling and/or coordination of care, which would justify that level.
 
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