Wiki Time based coding - code be rounded up

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riklma

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For an E & M code if the physician selects the 99213 code and documents that he spent 22 minutes with the patient and greater than 50% was spent counseling the patient. He documents what was discussed and this coinsides with the nature of the presenting problem. Is there any documentation from CMS or any one that shows because of time can this code be rounded up to 99214 or any documentation that the total time must be met before you can code the 99214?

Thanks for the help
 
If you are billing based on time, you must meet the minimum amount of time for the level you are billing. So, in order to bill 99214 the physician would need to spend more than 50% of 25 minutes. Even though 99213 says for 15 minutes, you cannot "round-up" the time if he spent 22 mintues - he would need the extra 3 minutes!

•When codes are arranged in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used. See also the E/M Services Guidelines
◦NOTE: Medicare has stated that they will not accept this rule for time-based E/M services. The expectation is that the typical time for each code must be met or exceeded
 
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Time not always secondary

Cynthia,

I don't think so.Unless something has changed as stated above if over 50% of the visit is counseling and coordination of care, time is the primary determinant of the E&M Level of care. It is certainly ideal if elements of HPand MDM are properly documented, but they don't drive the level when the majority of the visit was about counseling and coordination of care. This would kind of compare to Critical Care which is time driven. certainly the chart should support the CC coding, but the E&M guidelines for levels are not a factor.

jim
 
Per the CPT E/M Guidelines, Time is considered to be the controlling factor for the code selection of an Office or Outpatient Evaluation and Management code when counseling and/or coordination of care dominates (more than 50%) the face-to-face portion of the encounter. This face-to-face time (or intraservice time) includes time spent with the patient and/or family performing such tasks as obtaining a history, performing an examination, and counseling the patient.

Your question does have some merit. Here's an excerpt from the Evaluation and Management Guidelines from CPT: "It should be recognized that the specific times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances."

Because CPT identifies the times as averages, that represent time ranges and not specific benchmarks, it is understood that there can be some variability. You could have an established patient that takes 20 minutes, and Time dominates the encounter, and you can use your discretion as to whether that should be coded as a level 3 (which requires 15 minutes) or a level 4 (which requires 20 minutes.) In terms of rounding up or rounding down, it is permissible - but be consistent. If you as a coder or auditor are conservative and you generally round down unless the time is extremely close, that's fine. Just have a defined policy for your office, include it in the compliance policy, and make sure everyone is on the same page. That's the most important thing.
 
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Sorry, I can't make heads or tails out of that question. Was that supposed to be a quote? You're going to have to clarify that question - I'd like to help, I just don't understand what you're asking.
 
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