Wiki Time vs. MDM-Clarification Please

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dballard2004

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I have a question about using time vs. MDM to determine the E/M level. Here is the scenario.... for an established patient, the MDM supports 99213, but the provider states he spent 32 minutes in total on the encounter which is 99214. I know the guidelines state you can use time or MDM in selection of the level, but does the time have to actually reflect the MDM? I have an auditor saying that based on the MDM, this should only be a 10-15 min discussion and 32 mins would not be accurate based on the complexity. How do I handle this? Thanks.
 
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The thing is, though, that time isn't only face-to-face with the patient. It's also things to specifically prepare for that patient's visit - reviewing previous notes and stuff like that. (I can't remember what all the activities are that are included in that at the moment, but a quick google search should lead to what they would be.)
 
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carlystur said:
The thing is, though, that time isn't only face-to-face with the patient. It's also things to specifically prepare for that patient's visit - reviewing previous notes and stuff like that. (I can't remember what all the activities are that are included in that at the moment, but a quick google search should lead to what they would be.)
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Thanks. I guess for me, it is the fact the provider is telling me basically to go back to my provider, shake my finger and imply that they are being dishonest in their documentation. I don't know that.
 
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Hi there,
Unless the auditor can point to a specific payer policy, there's no such thing as matching the MDM to the time for a code (or vice versa).

MDM and time are two independent concepts. The CPT editorial group deliberately structured the new coding guidelines to allow providers to select the coding method that benefits them, on a case-by-case basis if they want. It may be a rare case of something that sounds too good to be true actually being true.

Another issue may be here:

I have an auditor saying that based on the MDM, this should only be a 10-15 min discussion and 32 mins would not be accurate based on the complexity.
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Perhaps the auditor has forgotten that the provider can count time for actions related to the patient's care before or after the face-to-face encounter, on the date of the visit? The actual discussion time could have been one part of the work the provider did on that day.

I know CPT Assistant had a number of Q&As about time vs. MDM because it really does seem too good to be true. But it would take me a while to dig one out. You might try going over the information from the initial update launch here with the auditor https://www.ama-assn.org/practice-m...ng-cpt-evaluation-and-management-em-revisions

But honestly, I never know what to do if someone reads the guidlines and just doesn't believe them. 🤷‍♀️
 
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It's difficult to say without the documentation. However, it is one or the other, you don't mix both. If it states 32 minutes and it is documented as to what was included in that time it's over 30 mins = 99214 if established.
Time alone may be used. Is there a medical appropriate history and/or exam? Total time includes face to face and non face to face personally spent by the QHP.

Now, I will say, if you have an auditor that has been looking at a range of this provider's established E/M over time, AND that provider somehow *always* documents that the visit is 32 minutes, and *always* codes by time alone, then I might start digging a little more. However, at face value, if documented properly, and it meets the E/M requirement and is coded by time with time documented, it would be acceptable.
 
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Fairly recently, CMS stated that its auditors would evaluate the documentation in records where time was used to determine the CPT code level. Also, you have to understand that the auditors will have a general idea of how long a visit should take based upon the number and complexity of the problem(s) dealt with during the exam. If an exam does truly take 32 minutes for a fairly routine problem, the provider should document why that exam, for that problem, took longer than you would normally expect it to.

Tom Cheezum, OD, CPC, COPC
 
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Cheezum51 said:
Fairly recently, CMS stated that its auditors would evaluate the documentation in records where time was used to determine the CPT code level. Also, you have to understand that the auditors will have a general idea of how long a visit should take based upon the number and complexity of the problem(s) dealt with during the exam. If an exam does truly take 32 minutes for a fairly routine problem, the provider should document why that exam, for that problem, took longer than you would normally expect it to.

Tom Cheezum, OD, CPC, COPC
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Thanks so much! I appreciate the insight.
 
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