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Common misconceptions regarding coding based on time
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One of the most frequent misunderstandings I come across when speaking with physicians and coders is how to code based on time.
If a provider spends at least 50% or more of the total time of the visit in counseling and coordination of care, then the Current Procedural Terminology evaluation and management (E&M) code chosen may be based on time. The note must document the total time spent with further documentation that 50% or more was in counseling. A statement such as “total time spent was 25 minutes, of which >50% was spent in counseling” suffices, as would “time of visit: 25 minutes, 20 minutes of which were in counseling and coordination of care.”
Confusion results when the visit is not exactly 25 minutes. If this is an established patient visit and the total time spent was 30 minutes of which greater than 50% was spent in couseling, then the code 99214 would be used. However, what if the total time of visit was not 25 minutes but 23 minutes? Would this be a 99213 or a 99214?
The CPT guide is not specific, only stating that the time specifications of each E&M code are “average” time spent. Based on my discussions with people who audit and/or teach coding for a living, this time should be considered an average and not a threshold that must be met or exceeded. That means that a 99214 may potentially be coded for all visits in the time range of between 20 and 32 minutes, as long as the note documents the total time spent and at least 50% or more was in counseling and coordination of care. Therefore, a 23-minute established outpatient visit, of which more than half was counseling, would be a 99214.
Another misconception is that if you did not meet the suggested average time, then you cannot use that code. That assumption would be correct only if you are coding based on time as I have just described. If you are not coding based on time then time is not a factor in determining which code to use. However, the history, exam or medical decision-making elements must meet the requirements for whichever E&M code is chosen.
An example would be an outpatient consultation for type 2 diabetes, uncontrolled, and severe dyslipidemia. You document a comprehensive history, a comprehensive exam and your medical decision-making is moderate. You would like to code a 99244. However, you spent only 45 minutes total time for that visit.
Can you code a 99244 (average time 60 minutes) or must you choose a 99243 (average time 40 minutes)?
If the history, exam and medical decision-making elements documented in the note meet the requirements of a 99244, then of course you can use that code. You will not be penalized for being efficient as long as your documentation supports the code chosen. Time is not a factor except when counseling takes up more than 50% of the visit and you choose to code based on time rather than other elements.
There are several coding courses available for physicians and their staff interested in learning more. I highly recommend the American Association of Clinical Endocrinologists Basic and Advanced Coding Course. The next time this course will be offered is October 23-24 in Phoenix, Ariz.