Tighten Up Your Documentation for Coding E/M Based on Time

Mon, Nov 21, 2016 --

Compliance, CPT Codes

coding E/M based on time

If you almost always choose your E/M codes based on history, exam, and medical decision making (HEM), you may be hesitant to code based on time. But ignoring this opportunity could be leading you to report lower level E/M codes that reimburse at a lower rate than you deserve. Take your time-based coding confidence up a notch with these documentation tips.

Tip 1: Know What the Authoritative Rule Says

The first step to knowing what documentation is required is simple: read the official rule. It’s in the E/M guidelines section of the CPT® manual under the heading “Select the Appropriate Level of E/M Services Based on the Following.”

In short, the rule states that when a provider spends more than 50 percent of an encounter on counseling and/or coordination of care, then you can use time as the controlling factor to determine the E/M level. In the office setting, this refers to face-to-face time. Floor/unit time counts in a hospital or nursing facility.

The rule also states, “The extent of counseling and/or coordination of care must be documented in the medical record.”

Tip 2: Look for Total Time and Time on Counseling

To feel secure that coding an E/M based on time will stand up to scrutiny, work with providers to document both total time for the encounter and the amount (or percentage) of time spent on counseling and/or coordination of care. Using start and stop times for both the visit total and the counseling portion is another good method, and some EHRs may have features to help with this.

Do this: Documentation that “I saw this patient face-to-face for 27 minutes and spent 15 minutes of the encounter on counseling the patient” shows the provider spent more than 50 percent of the 25-minute visit on counseling.

If this is an office visit for an established patient, the mention of 15 minutes counseling during a 27-minute encounter helps support reporting 99214 (…Typically, 25 minutes are spent face-to-face with the patient and/or family) even if the HEM calculation doesn’t meet the complete requirements for this level 4 code.

Don’t do this: Saying “I had a long talk with the patient” isn’t going to cut it when an auditor checks to see if more than half the visit was spent on counseling.

Tip 3: Check for a Description of What Occurred

Just offering the time involved isn’t enough. Medicare’s 1995 and 1997 E/M documentation guidelines state that “the record should describe the counseling and/or activities to coordinate care.”

The description may detail discussing topics like the patient’s diagnosis, prognosis, and treatment options.

A template can be useful to help show the provider exactly what information you need to see documented, but avoid text that’s tempting to cut and paste. Auditors may see cookie-cutter text as a sign they need to dig deeper. The documentation of the counseling and coordination of care should be specific to the patient and should support medical necessity for spending the reported time with that patient.

How About You?

Do you code E/M based on time? What steps have you taken to ensure adequate documentation?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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