Familiarize yourself with CPT® guidelines to ensure proper coding and payment of evaluation and management services.
Although evaluation and management (E/M) services have been around for many years, reporting timed-based services can still be confusing. Between the multitude of rules for the various E/M categories and the different methods for leveling, it’s not surprising that many coders find it hard to keep it all straight.
And now the codes and guidelines for new and established physician office/outpatient E/M services are changing! If you’re confused by all of this, don’t get discouraged. We’ll break it all down in this article, starting with a little coding history.
Evolution of Coding Practices
Prior to 1992, the CPT® code book did not include time as a factor, although it was implied. E/M codes only had descriptors, such as brief, limited, and extended, and did not include many details or definitions. This was a big problem. Physicians struggled with determining what E/M level to report, and payers could not assess the clinical documentation and reported E/M levels objectively.
Then, in 1992, the American Medical Association (AMA) began to include time as a factor to assist in selecting the most appropriate E/M level for office and other outpatient services, inpatient services, and consultations. The times listed in the CPT® code book were considered the average time a physician spends caring for a patient, and while this was a step in the right direction, it did not take all the subjectivity away. We were still left with ambiguous guidelines.
Since 1992, time-based coding for most of the E/M categories, as well as many other CPT® codes, has evolved. Today, we use terms such as total time, total visit time, face-to-face and non-face-to-face time, greater than 50 percent, CPT® midpoint rule, and rounding.
Keeping all these terms straight can make a coder’s head swim. Don’t worry; it’s actually relatively easy to apply time-based rules if you comprehend the terminology and have a clear understanding of the CPT® code descriptors and documentation requirements.
Time to Set Things Straight
Let’s start by clarifying face-to-face versus non-face-to-face time-based services.
Face-to-face time is defined as the time a provider spends directly interacting with the patient and/or family or caregiver and includes tasks such as obtaining a history, examination, and counseling. In 2008, the AMA introduced codes for Counseling Risk Factor Reduction and Behavior Change Intervention. These codes can be used when counseling patients on specific behaviors that may lead to illness or exacerbate an existing condition.
Non-face-to-face time is the time the provider spends managing the patient outside of an encounter, such as before and after direct patient care. Non-direct time includes discussions with other healthcare providers; reviewing the patient’s medical record; ordering tests, services, and prescriptions; and time spent performing services directly related to the patient’s care.
Total time is defined as the overall time on the day of the encounter during which a provider provides services related to patient care, even if the times are not consecutive. The time spent over the course of the day is totaled, with the day starting at 12:01 am and ending at midnight. The time calculation includes a provider’s face-to-face and non-face-to-face time. A provider’s total time may be calculated based on their start and stop times or simply a statement of total time.
Management — both face-to-face and non-face-to-face services — provided on the day of discharge is often under-documented and coded incorrectly. A common mistake is to only look at the provider’s total time performing the discharge planning and forgetting the key documentation requirements for the face-to-face portion, final examination, summary of the patient’s hospital stay, and discharge instructions. When in doubt about what to count, read the CPT® descriptors and guidelines.
Total visit time is revised for 2021 to include both face-to-face and non-face-to-face time personally spent by the physician
and/or other qualified healthcare professional(s) on the day of the encounter. This does not include the time spent on activities normally performed by clinical staff.
AMA has provided us with a list of activities that may be counted toward a physician’s total time:
- 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 the health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
How is the definition of total provider time different than the new total visit time? AMA specifically states that this definition of total visit time only applies to coding office or other outpatient services (99202–99205, 99212–99215) and only includes the provider’s time, not that of ancillary staff. To avoid confusion, refer to the CPT® descriptors and documentation guidelines.
Say Goodbye to the Greater Than 50 Percent Rule
According to the Centers for Medicare & Medicaid Services (CMS), “The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection.” The greater than 50 percent counseling or coordination of care is a time-based rule released by Medicare to reduce some of the ambiguity of time-based coding.
CMS goes on to state, “For E/M services in which either key components or time is used for leveling, time must meet or exceed the specific CPT® code billed and should not be ‘rounded’ to the next higher level.” Here you have it, and it’s clear; rounding times up is not allowed on E/M services.
With the 2021 E/M code and guideline changes, there is one more consideration: You may no longer apply the “greater than 50 percent” counseling and coordination care rule to office and other outpatient E/M services.
Time Isn’t Always the Answer
Not every E/M service allows reporting the level based on time. This is why you must look at the CPT® code descriptors and other documentation requirements.
E/M services that are leveled based either on key components history, examination, and medical decision making or time using the greater than 50 percent counseling and/or coordination of care guideline include:
- Inpatient and Subsequent Services
- Observation Services
- Nursing Facility Services
- Inpatient Consultation
- Outpatient Consultation
- Domiciliary/Custodial Care
- Home Services
Midpoint Rule Minutia
Now let’s talk about the CPT® midpoint rule, which states, “A unit of time is attained when the midpoint is passed.” This rule may also be described using terms such as rounding up, halves, or 51 percent rule.
Take, for example, code 99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes: Eight minutes is past the midpoint of 15 minutes. If the time spent was less than eight minutes, then no code should be billed. If at least eight minutes is documented, however, you can report 99401.
Another example is 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour: For encounters lasting 31-60 minutes, you may bill this code. For encounters lasting less than 31 minutes, you cannot.
Tip: Documentation of time should be exact. Avoid vague wording such as greater than X minutes. Start and end times are also acceptable.
The midpoint rule only applies when there are no code- or code-range-specific time instructions included in the code descriptor or guidelines. To put it another way, when the CPT® code descriptor includes a code range, such as 5-10 minutes, greater than 30 minutes, “typically X minutes,” or each 30 minutes, then you should not apply the midpoint rule.
It is important to note that when billing Medicare or other payers that do not recognize the midpoint rule, the documented time must meet or exceed the typical time listed for the CPT® code billed.
You may apply the midpoint rule to services such as:
- Advance care planning
- Preventive medicine counseling
- Prolonged services
3 Tips for Mastering Time-Based Coding
More than ever, time is an essential component of coding E/M services. As coders we can eliminate the confusion surrounding time-based coding by following these three easy steps:
1. Get in the habit of reviewing the code descriptors for the key terms that differentiate the specific rules;
2. Understand how and when to apply the rules; and
3. Work with your providers to ensure their documentation can stand up to the scrutiny of any payer.
In doing so, we can ensure proper coding and payment of E/M services.
CMS transmittal 2121: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2121CP.pdf
2020 AMA CPT® Professional code book
AMA 2021 Code and Guideline Changes: www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf