November 10, 2023 | By Toni Elhoms, CCS, CPC, CPMA, CRC
On countless occasions, I have heard physicians and healthcare providers balk at the notion of learning how to level their E/M services based on medical-decision-making (MDM), and some will even go as far as to say things like “I don’t have time to bother with all that MDM stuff and prefer to only bill based on the time” or “I’ll just throw a time statement macro in the note to cover my bases since MDM is too subjective.” As compliance auditors and professionals, we see the results of this mentality in clinical documentation day in and day out with antiquated macros and note-bloat-heavy templates.
I still see “greater than 50% of the face-to-face time was spent in counseling/coordinating care” almost daily, even though E/M services are no longer calculated based on this criterion. If this isn’t a case of “kicking the can down the road,” I don’t know what is! To make a bad situation even worse, these myopic sentiments are often paired with ineffective operations leadership and support staff that refuse to confront these issues and further enable this poor decision-making. We, as compliance professionals, must remain diligent and peel back the curtain on all these decisions to assess the situation for potential compliance risk exposure.
While time-based billing for E/M services is permitted, let us not forget that not all time-based billing rules in CPT are created equally, which often results in conflating rules across different service categories. Within CPT Coding, we have service-based CPT codes and time-based CPT codes.
Categories of Time-Based Services
There are certain services (e.g., Chronic Care Management (CCM), Principal Care Management (PCM), and Remote Patient Monitoring Management (RPM)) that require a fixed time threshold to be met to qualify for compliant billability. Next, there are certain services (e.g., office-based E/M services, online E/M services, telephone E/M services) that encompass time ranges with established minimum times to be met to qualify for compliant billability time-based CPT codes. There are also constant attendance time-based services (e.g., Physical Therapy, Occupational Therapy, Psychotherapy) that require greater than half of the intra-service time to be met to qualify for compliant billability.
As compliance professionals, we must take it a step further and raise the issue of whose time can be counted towards each billable service and what level of supervision is required to report those services. This mixed bag of coding and billing rules often leads to physicians/providers/clinical staff conflating different types of time-based coding rules and subsequently billing for time-based services in situations that are improper and ultimately result in overpayments to the organization.
First, let’s start with the example of chronic care management services. Under the current rules, if the provider wants to bill CPT Code 99490, they must document a minimum of 20 minutes of total clinical staff time directed by a physician or other QHCP dedicated to that patient spent in the calendar month. In this scenario, providers can count time spent by clinical staff dedicated to CCM activities if the services are directed by the physician/QHCP and under their general supervision. It would be improper to count any activities unrelated to CCM in the total billable time per calendar month or to double dip CCM time with an overlapping service like transitional care management (TCM). It would also be improper to count time spent by clinical staff not affiliated with the provider or time spent with clinical staff based outside the United States (i.e., offshore care management companies) towards CCM billable time. Suppose the provider wants to bill CPT Code 99491. In that case, they must document a minimum of 30 minutes of personal physician/QHCP time dedicated to that patient spent on CCM activities in the calendar month. In this scenario, providers cannot count or combine clinical staff time dedicated to CCM activities because this CPT code is specifically for physician/QHCP personal time.
Second, let’s dive into the example of office-based E/M services (99202-99215). Under the current rules, if the provider wants to bill for CPT Code 99214 based on time, they must document a minimum of 30 minutes of total encounter time (up to 39 minutes) dedicated to that patient spent on the encounter date. This total time spent on the encounter date can only be provider time without any combination of clinical staff time. It would be improper to combine the medical assistant or nurse’s time dedicated to the encounter, time spent by the medical scribe, time spent teaching or precepting students/residents/fellows, and including any midlevel provider time since office-based services do not allow for split/shared reporting. It would also be improper to count any time towards the E/M level dedicated to a separately billable procedure or service, and time statements must make abundantly clear that E/M time is separate and excludes any procedure/other service time.
Thankfully, in 2024, we will return to fixed time thresholds for office-based E/M services! This will surely alleviate much of the confusion and disparities surrounding prolonged service billing and the mixed bag of payer policies we must navigate under the current system.
Next, let’s focus on constant attendance services using an example of physical therapy (PT) treatment. Many PT services are continuous attendance-based therapies, billed based on time and reported based on 15-minute increments. Under the current rules, if the provider wants to bill for CPT Code 97110 x 1, they must document a minimum of 8 minutes (Rule of 8s) of intra-service time personally spent by the provider and dedicated to that patient at the encounter. We’ll save all the payer policies regarding the rule of 8s for another time! Throughout this PT session, the provider must maintain visual, verbal, and manual contact with the patient. This total time spent on the date of the encounter can only include provider time without any combinations of clinical staff time. Unlike the other scenarios described above, the provider does not have to spend the full 15 minutes to fulfill the requirements for billing for the PT service. It would be improper to combine any time outside of the provider’s direct contact with the patient with the time counted towards this billable service.
So, it’s safe to say that even for the most seasoned professionals, it’s easy to get all these time-based coding and billing rules confused, which is why ongoing compliance audits combined with dialogues and education with our physicians/providers/clinical staff are imperative. Don’t just assume that your physicians/providers/clinical staff can keep all the hodgepodge of time-based billing and coding rules straight and compliant – we, as compliance professionals, MUST ascertain that this is done by diving deep into their clinical documentation and clinical workflows.
These regular touchpoints and interactions will aid you in uncovering some of the main sources of conflation.
The moral of the story – make sure to educate your physicians/providers/clinical staff about the intricacies of time-based billing and coding rules, or the consequences can be catastrophic!
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices with time-based E/M services.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Review the NAMAS YouTube channel and Let’s Chat video postings on Social Media for more auditing and compliance tips!
Who is NAMAS?
NAMAS is an industry leader in medical auditing and compliance, backed by over 60 years of expertise as a division of DoctorsManagement, LLC. Our team of auditors and educators are highly experienced and hold a minimum of a CPC and CPMA certification, with over 10 years of auditing-specific experience.We take pride in being the original creator of the AAPC-affiliated CPMA credential, and our range of auditing education, resources, training, and services is vast. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all.
We firmly believe that our experience and proficiency make us the go-to authority in auditing and compliance. Our commitment to excellence and our innovative approach to auditing have helped us become the leading provider of auditing education and training in the industry.
If you’re looking to grow and excel in the auditing and compliance field, look no further than NAMAS. Our team is dedicated to helping you achieve your goals, and we are excited to continue providing top-quality education and training to professionals across the country.