Like many of my auditing colleagues, I entered 2021 with a solid understanding of the rules of the 2021 E/M Documentation Guidelines, but looked forward to seeing how they were applied in practice by the rendering provider.
Now that we’ve entered October, one area of great concern for me is how some providers are documenting service time. If you’ve not done so already, I’d suggest setting internal policies for what is allowed in time attestation statements and viewing this area of the documentation closely.
First, a refresher: The 2021 guidelines greatly loosened the rules for what could be included in the amount of time used for billing purposes. Essentially, any time spent personally by the rendering provider in service to the patient on the date of service, including tasks such as reviewing old records, documenting in the medical record, counseling the patient, reviewing test results not being separately billed – all of these functions can be considered part of the time attestation.
About the only restrictions on documentation of time are that the provider cannot count time spent on separately billable services, cannot count time spent on tasks ordinarily performed by ancillary staff and should account for the time in a medically necessary way.
Some providers are using this guidance as a license to code all 99215s for established patients. I’ve worked with at least two primary care providers routinely billing 99215 along with one or two units of 99417 and that worries me as I’m sure it is going to catch the attention of payers sooner or later.
In order to help me educate physicians, I’ve developed some parameters for how I consider time as I audit charts that I’ll share with you:
- Be wary of serial time documenters: When a provider regularly or always documents service time in a way that deviates from the medical decision making, I make sure to inform the provider that this will be an external risk and point out the reasons why. As a non-clinical auditor, I don’t tell providers what to examine or what to document, but I could see a payer auditor suggesting a provider is “over-documenting” relative to medical necessity and claiming time as a result. The fundamental question is – what is the rationale for this provider taking a longer time than is typical and does the record support it?
- “Catch-all” attestation statements: A time attestation should include specifically how the provider spent the time serving this patient. That doesn’t mean an attestation can’t be used, but it should consider the specifics of the service. If a provider states in an attestation statement that it included discussion with a caregiver, but there is no indication of the involvement of a caregiver, it could be a problem. Same with tasks such as ordering tests – if it is documented, then I expect to see ordered tests for that patient.
- Try to be exact: When time attestations include so many details about things that can be done outside of the presence of the patient, I am more wary of every attestation magically being 30 minutes. When it had to be face-to-face with the patient, at least the appointment calendar could be used to verify. If a provider is always documenting time, I would suggest adding up the total daily time to give perspective on whether there is a risk of an unnatural day.
- Consider medical necessity: One thing that has not changed in 2021 is that medical necessity remains the overarching criterion for code selection and work and code assignment should be based on that reality. If a provider is suddenly coding a lot more 99215 level services, look closely at the workup and presenting problem and consider whether it is warranted.
- No approximations: I will consider a note that says the provider spent “at least” 30 minutes, but a note that states “about” 30 minutes will not support 99214. The distinction to me, even as I prefer actual time, is that 29 minutes is about 30 minutes and is not supportive of assigning 99214.