Coding by Time
June 12, 2023
The most common questions we receive from physicians and nurse practitioners involve the second major component in medical decision-making: documenting the total time for evaluation and management (E/M) services provided on the day of the patient visit.
In this issue of Coffee & Coding, we are going to address some of those questions about coding by time.
What, precisely, is coding by time?
Answer: For coding purposes, time for E/M services is the total time on the date of the encounter.
What does it include?
- The face-to-face time with the patient and/or family/caregiver.
- Non-face-to-face time personally spent by the physician and/or other qualified healthcare professional(s) on the day of the encounter (including time in activities that require the physician or other qualified healthcare professional).
- Time regardless of the location of the physician or other qualified healthcare professional (e.g., whether on or away from the inpatient unit or in or out of the outpatient office).
What does it NOT include?
- Time in activities normally performed by clinical staff.
- Time spent on the performance of other services that are reported separately.
- Teaching that is general and not limited to discussion required for the management of a specific patient.
Is special documentation needed in order to bill for time?
Answer: Yes. The general rule, as we noted in an earlier edition of Coffee & Coding, is: “If it is not documented, it did not happen.” Documentation is imperative in order to get credit for all you do.
Here are some specific guidelines:
- The total time on the date of the encounter spent caring for the patient should be documented in the medical record when used as the basis for code selection.
- For shared or split visits (i.e., when two or more individuals jointly meet with or discuss the patient), you should count only the time of one individual, usually the provider signing off on the overall care of the patient (or billable NPI).
- Physician or other qualified health care professional time includes the following activities performed on behalf of the patient:
- Preparing to see the patient (e.g., review of tests).
- Obtaining and/or reviewing separately obtained history.
- Performing a medically appropriate examination and/or evaluation.
- Counseling and educating the patient/family/caregiver.
- Ordering medications, tests, or procedures.
- Referring and communicating with other healthcare professionals (when not separately reported).
- Documenting clinical information in electronic or other health records.
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
- Care coordination (not separately reported).
What if I see the patient for 75 – 120 minutes?
Prolonged outpatient evaluation and management service(s) time (with or without direct patient contact) involves time beyond the required time of the primary service. When prolonged time occurs, the appropriate prolonged services code may be reported. An additional CPT code is required for each 15-minute increment, along with the code for the total duration of the particular type of visit.
Below is the timetable with the limits outlining when to use an additional CPT code to bill correctly for the total time spent.
CPC, CFPC, CEMC
Senior Manager, Regulatory and Coding Compliance