Answers to 20+ E/M Coding and Time-Based Services Questions
We’re tackling your questions from our recent webinar, “Best Practices for E/M Coding and Other Time-Based Services.” You savvy coders had some great inquiries throughout the webinar, so take a look at our answers below. Don’t see your question answered? Comment on this blog post and we will answer it for you!
Can time spent on hold by the provider for prior authorizations count?
- The total time should be performing clinical functions of the evaluation. Being on hold for authorizations is not considered clinical function of the evaluation.
Can you explain instances when we can give physician credit for review of unique tests when they were not the one who ordered the tests?
- When results come from an external source, or when the provider reviews a lab report for a test he did not order, you can count under unique test(s).
If you are billing critical care in the ER and you start seeing the patient at 11 pm and end at 1 am, which date do you use?
- You can use either date.
In the example of 99202, if you spend 10 minutes with the patient, you would base your code selection on MDM, correct? Because you have not met the 15 mins.
What about a nurse that is doing some diabetic teaching with a patient after the visit with the doctor, can that be documented with 99415?
- No, the total time is for the physician's total time. Use a separate code for diabetic teaching.
If the physician finishes the chart or just closes the chart on next calendar date, they cannot include any of that time, correct?
- The total time does not need to be documented on the calendar day it occurred. It only needs to include the time spent on the day of the visit.
Who needs to document the time for the clinical staff (for the extra services)?
- Whomever is performing the service and documenting in the patient health record should document their time.
From a CMS perspective, observation is still an outpatient service. Is there ever going to be a time that any provider would use an outpatient code versus the inpatient code?
- If the patient is in OBS for greater than eight hours (per CMS), you will use the same-day observation codes. If the patient is classified as an outpatient, per CMS only the admitting provider can use the observation codes. Other providers will need to use the outpatient codes.
For shared or split visits – does the provider that performs the "substantive" portion also have to physically "document" that portion as well, or simply state in an attestation that they performed it if selecting level back on MDM vs. time?
- The provider must actually document the substantive portion. The attestation does not suffice.
Regarding prolonged code office codes 99205 or 99215, the CPT® 2023 is still stating it is one minute beyond per the grid in book under 99205, 99215, and 99417. Is that your understanding as well?
- For 2023, AMA instruction indicates that the prolonged add-on code 99417 is reported only when the maximum time of the E/M category code (99205) has been exceeded by 15 minutes. AMA Link: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Regarding incorrect time examples: if a provider does bill for that knee injection and wants to base their E/M on time, would it be appropriate to document time and include a statement such as "doesn't include time spent on knee injection?"
How can history or exams be used as a key component when they are no longer utilized from a leveling perspective?
- History and examination are no longer used as a key component for calculation of the E/M code, however, there are still documentation requirements which is why we left that requirement on the table.
Is split/share only for Medicare patients? Do we still use FS modifier?
- Some payers follow CMS split shared guidelines. Yes, you will still use the FS modifier.
For critical care, does the physician need to be immediately available (unit, floor, bedside) for calculation of time?
Regarding prolonged clinical staff time. As far as I know, there is no base E/M code for clinical staff time, so I'm confused as to the use of the clinical staff prolonged codes. Are they used in addition to E/M codes billed by physicians or other qualified healthcare professionals? Does the physician/OQHP have to be present during the prolonged clinical staff time? If the time exceeds the base time for the professional E/M code billed, do we bill prolonged time codes for the provider/OQHP AND the clinical staff?
- The codes are added on to the provider's E/M code. The provider must be in the office but does not have to be in the room. You cannot bill the time twice, use either the prolonged or the clinical codes as appropriate.
We were told by an MD/CPC that if the doctor is attesting to spending the time, we need to accept that –even if each visit says, "I spent 56 minutes with the patient......." and reference to plan and coordination of care is sparce?
- Coders and auditors should accept the documented time, however, educate the provider that the note is a legal record and the A&P must be complete.
Can you please clarify if there is a difference on how CMS and AMA calculate prolonged time for inpatient services (99418/G0316)?
- The time calculation and rules for the time ranges are the same. CMS just requires their G code.
To clarify, when you say CMS requires start and stop times, which services does that apply to? All E/M?
- Start and stop are not required on E/M services. It is recommended to document start and stop time for behavioral health services.
How would you handle a provider who reports the same amount of time in every note? The time normally supports either a level 4 or 5. Also, it is appropriate for a provider to document "I spent at least XX minutes..." or should the time be specific?
- In these scenarios, it is recommended to perform a time audit in which the total time and the number of patients for that given day are viewed. Additionally, shadowing the provider during the visits could provide additional insight.
An ER physician consults a specialty physician. The specialist performs consultative services in the ER. Can the consulting physician report 99245, 99417 in the ER as appropriate per supporting documentation? Also, are these codes acceptable when the patient is seen in the ER by the consulting physician on subsequent days due to lack of obs/hospital beds? Please clarify as the latest CPT® Coding Assistant, March '22 guidance states, "except services provided in the ER."
- Yes, a consultant may report 99245 and 99417 when services are performed in the ER. The intent of the visit must meet the new AMA Consultation definition.
Can E/M for ER be billed in addition to critical care time? Previously we rolled up to the critical care time code and did not also bill the E/M.
- This guideline did not change.
Do we know how payers are auditing time-based services under the updated E/M guidelines? Any recommendations for documenting time statements?
- Payers are watchful and will look at high-level E/M services, particularly if a prolonged E/M code is billed with a high number of units. AMA states the medical record should support the E/M level of service, so if the visit was indeed very long, then a brief description of the activities performed associated with the E/M service to support the total time is always best practice.
Is it your recommendation when deciding how to level a visit to use MDM or time, whichever is more beneficial for the highest level, or to always use MDM first to see if the medical necessity substantiates the E/M level regardless of time documented?
- AMA and CMS allow either MDM or time, whichever is most advantageous to the provider. The AMA F&Q addressed this issue: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management-em-revisions-faqs
If you have documentation that a provider claims they spent X amount of time, but documentation doesn't support the time-based coding, could it be considered under coding, or are there any repercussions to having the documentation in the chart?
- If the time is documented, it should be allowed and would support time-based coding.
90834 - Isn't it 38-52 minutes? Halfway between 30-45 and 45-60? You said 23 minutes. Just want to clarify, please.
- Code 90834 is listed as 45 minutes with the patient. More than halfway is 23 minutes.
With total time for shared/split, both providers have to document their time to determine which to bill under?Yes.
With shared/split do both APP and MD have to be face-to-face?
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