E&M coding: Element-based or time-based?

Aug. 26, 2015 / By Rebecca Caux-Harry

I went to see one of my physicians today. She at her computer, me in a chair, discussing the multiple medications I’m taking, and the resulting side effects. If you’re a regular reader of my blog, you’re aware of my recent health challenges. I try not to think about what it was like before having a drawer full of medicine bottles but, I’m just whining. I know I’m lucky and I know I’m basically healthy. I’m probably a bit spoiled, too. But, back to the office visit today. My doctor and I talked for a long time. We reviewed my extensive (for me) list of medications and I complained about those side effects. She proposed a different medication regimen, then we discussed the risks associated with this change. I had a lot of questions, she consulted some studies online and we talked some more. At the end of this visit, I was examined and the impression and plan were discussed.

For you E&M coders out there, you’re tracking this visit in your head; coding it. Which way would you code, element-based or time-based? Because this visit was mine rather than a case I’m coding, I don’t have the record to refer to. But, it got me thinking about coding based on time and prolonged services. When an E&M service is coded based on time, counseling and coordination of care need to be the greater part of the visit. The provider must document the total time spent, a brief summary of the discussion and any elements of the E&M services also provided, like a review of systems. For most E&M codes, there is a typical time spent providing face-to-face care in the descriptor. So, for an established patient office visit, the highest level of care, 99215, has a typical time of 40 minutes. This is the time used to select a level of coding based time. Some clinics/payers use this as threshold time, some use it as average time.

What if the physician provided a problem focused history and exam, and documented straight forward medical decision making? Normally, this would be coded 99212. But, if the physician documented that she spent a total of 45 minutes on the visit and provided counseling and coordination of care, what is the right way to code?

The descriptor of 99212 includes a typical time of 10 minutes. There’s another 35 minutes of service provided that should be reflected in the coding. Looking at the information in the CPT book under Prolonged Services with Direct Patient Contact, I’m guided to codes 99354-99357. These codes are time and location based, and are add-on codes. For prolonged services less than 30 minutes, no additional coding is appropriate, as this time is captured in the base E&M code selected for the service. However, following CPT guidance, 30-74 minutes of prolonged services in the office can be reported with 99354 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service). So in this example, I could report 99212 and 99354. Or, if the physician documented that counseling and coordination of care dominated the visit, I could choose to ignore the history, exam and medical decision making and code simply based on time, which would be 99215.

In those rare circumstances when a physician spends greater than an hour providing care, there are additional add-on codes to capture 75-104 minutes, and 105 minutes or more with 99355 or 99357, based on place of service. But, remember, these are face-to-face codes. For non-face-to-face services, 99358-99359 are the correct codes, regardless of place of service. They are also add-on codes to be submitted in addition to the provided E&M service. These non-face-to-face codes are not to be used in place of, or in addition to, Chronic Care Management or Transitional Care Management Services. So, if E&M services extend beyond the typical time in the descriptor, take a look at prolonged care coding to see if the service qualifies for additional codes. And, by all means, ask physicians to document their time when those E&M services become long discussions. This is certainly a valuable service provided to the patient and should be reimbursed.

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.

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