The value of encounters: It’s about time

July 6, 2020 / By Allison Morgan, MS, CPC

Time flies… 2021 is approaching quickly, bringing with it anticipated E/M changes. A primary focus of the upcoming changes is the element of time and its evolving role in CPT code selection for outpatient office visits. Gone are the criteria of counseling and/or coordination of care comprising over 50 percent of the visit. Instead, time can now stand on its own when it comes to reporting outpatient services.

While time as a driver for code selection is not a new concept, the dynamics behind reporting it are now in the spotlight as a result of the 2021 E/M updates and the recent increase in telehealth services. It’s important for coders and providers to understand that while time is a tangible way to capture the value of physician work, not all codes that factor in time as a component play by the same rules. Properly capturing and documenting time is critical for compliant reporting and optimized reimbursement.

Here are some things to remember when it comes to reporting time…

Updates to total time in 2021

The 2021 updates to outpatient visits will define “total time” as the inclusion of both face-to-face time and non-face-to-face time. Providers should familiarize themselves with all the tasks that can now be counted toward time to capture the appropriate level of service. A full list of the updated actives can be found on the AMA’s website.

Prolonged services

Review and become familiar with time-based add-on codes when it comes to reporting prolonged services. An aspect that is sometimes overlooked with prolonged services is the additional time spent with the patient does not necessarily need to be continuous, however other factors should also be considered when selecting the appropriate code:

• Be aware of the setting in which the prolonged service is taking place.
• Keep track of the additional time counted specifically toward the prolonged time, as these codes are reported in time increments separate from their primary CPT code counterparts.
• Document and track if the prolonged time is direct or indirect.
• Make sure the activities included in the prolonged service cannot be reported separately in another procedure.

Not all time is created equal

Total time for reporting outpatient office visits is included in the 2021 updates, but be aware that what counts toward the time component for services performed outside outpatient settings can vary. Services such as critical care, psychotherapy, telephone services, hospital discharge management, and many others include time as a component for code reporting, and how time is included diverges based on the service type.

Be sure to read all guidance and section notes in CPT to apply correct codes and validate how the provider’s work can be counted toward time for those services. Educate providers to document these tasks in their notes to support code selection.

EMR capture

Because time can include services performed by the provider or other qualified healthcare professional and the services included can involve direct contact or non-direct contact with the patient, it’s important that practices track these actions as they may not be consecutively performed. EMRs (electronic medical records) should allow for tracking and documentation of these activities including time stamps, location reporting and authentication practices to allow for auditing to certify the work performed.

Documentation   

Educate providers on how time is documented directly in the note based on the type of services performed. While time may be the driver for code selection, the work performed during that time should corroborate and support those tasks that are included during that time.

Review how your practice documents time in an encounter. Encourage reporting time in an established, dedicated section of the note to promote consistent reporting and capture for easy reference.  When it comes to the actual record of time, determine a method that will work best for your practice, your coders, compliance team and your vendors. Will providers document a start and stop time or document the total minutes? Consider factors such as whether your CAC (computer-assisted coding) and EMR can support arithmetic actions to add up the total time and the probability of human miscalculation when adding up minutes.

The 2021 changes to outpatient E/M services reflect the ongoing value being placed on capturing provider’s time and efforts. Accurate documentation and understanding of time will ensure proper reimbursement… Remember to make time count!

Allison Morgan is a clinical development analyst at 3M Health Information Systems.

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