February 12, 2021 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O
A few weeks ago, NAMAS presented a webinar about 2021 time and prolonged services. The flood of participant questions made it very obvious there is still uncertainty about how to appropriately use time to select the level of office and other outpatient E&M visits. Although each inquiry was worded differently, most of them wanted answers to a similar group of questions:
- Whose time is counted to determine the level of E&M visits?
- What work can be included in the time counted?
- Do start and stop times need to be documented?
- When should time be used instead of medical decision making (MDM) to select an E&M level?
So, using the new guidelines found in CPT for the office/outpatient services (99202-99215), let’s address these questions.
“For coding purposes, time for these services is the total time on the date of the encounter. It includes both the 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 (includes time in activities that require the physician or other qualified healthcare professional and does not include time in activities normally performed by clinical staff).”
Many of the questions revolved around whose time can be counted. In addition to what is in the guidelines above, we can find the following about time for 99202-99215 on the AMA website: “The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM.”
We can see in the guidelines and the definition that only the time of the physician or QHP on the day of the face-to-face visit is used to select a level of E&M. However, some of the questions made it obvious not everyone understands who qualifies as a QHP.
The AMA comes to the rescue: In 2013 they defined physician or other QHP as “an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” Because clinical staff such as medical assistants or LPNs do not meet this definition, their time is not used to calculate the total time of the visit. The guidelines reinforce this in the parenthetical statement “(includes time in activities that require the physician or other qualified healthcare professional and does not include time in activities normally performed by clinical staff).”
Now that we have clarification of whose time is (or isn’t) included, let’s look at what work is included in the time. A provider asked if the following time statement would support the use of time for a new patient visit: “Today, greater than 90 minutes were spent evaluating the patient, reviewing prior labs and diagnostic imaging, performing a breast ultrasound and biopsy, and counseling the patient on the treatment plan.”
Let’s go back to the guidelines. The AMA provides the following examples in the 2021 CPT manual:
“Physician/other qualified health care professional time includes the following activities, when performed:
- Preparing to see the patient (eg, 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 health care professionals (when not separately reported)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)”
In the example documentation above, it is obvious part of the time was spent in the E&M activities included in the list. However, some was spent in the performance of the ultrasound and biopsy. These services are in addition to the activities of the E&M, not part of the E&M time (can you say double-dipping?). The physician amended her time statement for the visit to read “The total time of today’s visit is 90 minutes. 70 minutes were spent evaluating the patient, reviewing prior labs and diagnostic imaging, and counseling the patient on the treatment plan. 20 minutes were spent in separately reportable services.”
When time is used to determine the level of E&M for 99202-99215, the time does not have to be continuous, non-face-to-face time can be included, and the visit itself no longer has to be dominated by counseling and coordination of care. However, for all other sets of E&M codes (i.e., inpatient, observation, home, etc.) these new guidelines do not apply. Refer to CPT for instructions about using time in these other settings.
Quite a few questions have been raised about whether start and stop times are required to support the use of time for 99202-99215. If you closely read all the new guidelines in CPT about time, and even if you cull thru the AMA E/M Office Visit Compendium 2021, you will not see reference to start and stop times. Both the guidelines and the Compendium only mention total time.
The AMA/CPT has been mentioned a lot in this article. Why? Because AMA creates and maintains the CPT codes and their descriptors. The definitions and guidelines about how time relates to an E&M visit are the responsibility of the AMA. They do NOT create reimbursement policies. That is up to each of the insurance carriers, so to answer this question we will have to refer to each of the carrier policies to determine if start and stop times will be required. It is quite possible we will find some carriers want start and stop times along with a description of the work performed, while others may only require total time.
How will we know when to use time vs MDM? I’m sure it doesn’t need to be said but just in case, if time isn’t documented we won’t be using it. Otherwise, the decision to use MDM as opposed to time will be driven by the presenting problems of the patient and the time and complexity of the visit.
Think about it this way: Mr. Trey presents to Dr. Quick for follow-up. Dr. Quick addresses three chronic conditions and manages the prescriptions. He documents 15 minutes for the visit. MDM supports a level four service; time supports only a level two. This visit would be reported using MDM.
Later that day, Ms. Worried Well comes in to discuss some information she got from Dr. Internet. She has no clearly defined complaint but thinks she may have a deadly disease based on her extensive research. Dr. Quick documents 45 minutes was spent discussing the research and reassuring Ms. Well that she quite healthy and encouraging her to avoid Dr. Internet in the future. The MDM supports a level two; the time spent supports level four. We would report the level based on time in this example.
What do you do if the time documented does not reach 15 minutes for a new patient visit or 10 minutes for an established visit? You must use MDM because you haven’t met the minimum threshold needed to support a code using time.
Using the 2021 guidelines for 99202-99215, we addressed whose time counts, what activities are included in time, start and stop time vs. total time, and when to use time vs. MDM. It has been six weeks since the New Year rang in the biggest changes to E&M since the 1995 and 1997 guidelines were released. Considering there are still differing interpretations about the older guidelines, it is reasonable to believe there will be differences in interpretation of the 2021 guidelines. These differences are part of what makes having an up-to-date, living, breathing compliance plan imperative. Having written policies about things like requiring start and stop times will make sure the compliance team, coders, auditors, and providers are all on the same page.
Until next time, stay well.