Face-to-face time

Only the amount of time spent directly with the doctor is counted towards billing.

Your patient is a child with strabismus, and you have recommended eye muscle surgery to his parents. While the physical examination of the child only took 10 minutes, the conversation with the child’s parents was long and involved. Your discussion of the informed consent took 30 minutes of face-to-face time. The chart documentation contains a detailed history and a detailed exam. From an evaluation and management perspective, your decision making can be characterized as moderate.

What level of service should be billed for this established patient eye exam?

At first blush, the level of service would be 99214; however, the extraordinary amount of time dedicated to this case warrants reconsideration of that choice. On occasion, an exam may be very lengthy (eg, 40 minutes or more for an established patient, 60 minutes or more for a new patient). In those cases, document the physician face-to-face time in the record along with other appropriate comments, and choose the level of service according to the Table. Do not include time spent with technicians, dilating time or time for tests such as visual fields. Only face-to-face time with the doctor is counted. Note that the time need not be continuous; the doctor may leave the patient intermittently.

This approach should not be used commonly, and it would be deleterious to the practice to rely on face-to-face time as the only criteria for selecting an E/M code. However, for the extraordinary case involving extensive patient counseling, a notation in the chart about time spent will suffice to support your claim for reimbursement even if the other requirements have not been met. In this case, 99215 would be an appropriate choice because the cumulative physician face-to-face time was 40 minutes and a note to that effect should appear at the end of the medical record.