Time-based E/M coding: When the guidelines don’t fit

Sept. 28, 2016 / By Rebecca Caux-Harry

This month, Inside Angle blogger Rebecca Caux-Harry discusses E/M coding guidelines with Andee Andriole, 3M senior manager of outpatient consulting services.

Andee: Hey Rebecca, I was just reading some of your recent blogs and found the one where you discuss time-based E/M codes. Really interesting! Your personal perspective on this topic makes a lot of sense. Do you have time to explore time-based coding a little further from a patient’s perspective?

Rebecca: Sure, Andee. I know there are a lot of variables when considering coding based on time.

Andee:  So, in considering the guidelines related to counseling and coordinating care, we expect the documentation to include the physician’s discussion about instruction and counseling provided to the patient and other caregivers, right? And we expect the documentation to include those interactions related to coordinating the patient’s care, as well as the time spent in those efforts.

Rebecca:  Agreed. Documentation such as “I spent 45 minutes” is insufficient to support coding based on time. The provider needs to state that counseling and/or coordination of care dominated the visit, and the documentation should include a synopsis of that discussion.

Andee:  Documentation of prolonged services is also interesting. I still think of the E/M components and how long it takes the provider to perform those elements, such as a child who refuses to open her mouth for an exam. Another example is an adult who is evasive in responding to the provider’s questioning about their history, particularly history of present illness (HPI), but then has lots of questions related to the physician instructions. Again, time spent for the encounter needs to be documented.

Rebecca:  Very true. When looking at adding a prolonged service code, we need to know a few things: place of service, whether the prolonged service was face-to-face or not, and the total time spent. In order to use an add-on prolonged service code, the time needs to be 30 or more minutes beyond the usual service. These codes can only be appended to E/M codes that have a specified time in their CPT descriptor.

But you and I both know that patient visits rarely meet the defined guidelines we must follow. What if we have a record that falls between these two scenarios?   How would you code an office visit for an established patient where the provider documents an expanded problem-focused (EPF) history and exam and low medical decision making (MDM), and the provider documents total time spent of 40 minutes?

Andee:  Good question. We know that the E/M CPT code 99213 for an established patient visit states it typically takes 15 minutes, yet your example doesn’t support the counseling and coordination of care component. Therefore, E/M CPT code 99215 code (typically 40 minutes) is out of consideration.

As a rule of thumb for codes with time as part of the descriptor, the provider needs to exceed half of the time described to report the code. So, the first hour of the prolonged service codes requires that a minimum of 30 minutes have passed before the codes may be reported. Based on this information, your example of an EPF history and exam with low complexity MDM, and a total time spent of 40 minutes, would be coded the base E/M only (99213) because the reporting requirements weren’t met. In your example, billing the prolonged service codes would require at least 45 minutes [99213 – 15 minutes (base code time) + 30 minutes [first hour of prolonged service] = 45 minutes].

CPT Assistant October 2015 provides the following table:

Total Duration                                                           Code(s) Prolonged Services

Less than 30 minutes (less than ½ hour)                  Not reported separately

30-74 minutes (1/2 hr – 1 hr. 14 min.)                       99354 X 1

75-104 minutes (1 hr. 15 min – 1 hr. 44 min)            99354 X 1 and 99355 X 1

105 or more (1 hr. 45 min. or more)                          99354 X 1 and 99355 X 2 or more for each additional 30 min

Rebecca:  No question, there are a lot of coding guidelines out there, but there isn’t a guideline for every circumstance. As we both know, coding based on time isn’t always straightforward!

Andee Andriole is senior manager of outpatient consulting services with 3M Health Information Systems

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

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