November 26, 2021 | By Toni Elhoms, CCS, CPC, CPMA, CRC
As I am sure many of my colleagues can relate, I have frequently heard statements like, “All my E/M services are coded based on time because it’s just easier” or “I add total time to all my notes just to cover my bases”. These generic documentation practices have become even more prevalent with the new 2021 E/M Coding updates as many providers feel overwhelmed with the myriad of changes and default to time-based coding because it’s faster than learning an entirely new E/M leveling methodology. However, adding generic statements like these to clinical documentation without understanding the practical application and relevant leveling methodology can cause systemic issues for an organization.
First, these generic time attestations can lead to increased queries from coding and auditing professionals due to confusion about which leveling methodology is applicable to the encounter. Secondly, time-based coding alone can negatively impact reimbursement because moderate or even high complexity medical decision-making (MDM) can be achieved (in some cases) faster than the time ranges associated with each corresponding E/M code. For example, a 99214 requires a minimum of 30 minutes total time dedicated to the patient, but the provider was able to justify moderate level MDM based on addressing an unstable chronic condition and prescription drug management in a 15-minute visit. Third, this documentation practice can cause under-documentation of pertinent details related to the patient’s medical care because the provider is under the impression that the only thing that impacts coding is the total time dedicated to the patient. Lastly, this practice can lead to a false sense of security that all bases are covered from a compliance standpoint when in reality, these blanket time attestations can have the opposite effect. For example, a provider works 8 hours per day (480 working minutes) and sees 20 patients in those 8 hours. The provider documents a generic time attestation that 30 minutes total time was dedicated to each of those 20 patients without patient-specific details on how the time was spent. The math for seeing 20 patients x 30 minutes = 600 total minutes which does not add up to the total workday for this provider. When the total time documented exceeds the number of hours the provider worked, this will create many red flags for an auditor.
Moral of the story: Educate providers to document and code according to what specific activities dominated the E/M encounter. If the provider’s cognitive labor (MDM) dominated the visit, level the encounter based on medical decision making. If activities such as (but not limited to): preparing to see the patient, counseling the patient/family/caregiver, ordering medications/tests/procedures, communicating results, etc. dominated the visit, utilize time-based coding.
If you encounter provider documentation that includes generic time attestations, score out a few examples based on both MDM and time and use those examples as teaching points with the provider to demonstrate how this can negatively impact their coding and create red flags in the event of a compliance audit. If you encounter provider documentation that includes identical time statements across a group of patients, pull the provider’s schedule for that day, crunch some numbers, and show the provider how easy it is for an auditor to do the math and poke holes in the reliability of time spent with each patient. Most importantly, be diligent about monitoring these documentation patterns and trends!