Usage of Time Based Billing for CPT  Evaluation and Management

Lori-Lynne A. Webb

07.21. 2018

Within the guidelines of the CPT code book, CPT  has stated;  “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.  This includes time spent spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person in loco parentis, legal guardian).  The extent of counseling and/or coordination of care must be documented in the medical record.”

What this means to our physicians and providers, is that time alone can be used to select a level of care, and bill for our services regardless of the clinical documentation of history, exam and medical decision making that is noted or documented in the in the medical record for the current encounter or visit. 

The lack of complete documentation from busy providers is an area of concern that many coders see and take note of when performing coding audits in their role as a coder/clinical documentation specialist. Physicians are not consistently documenting the “nuts and bolts” of the core CPT criteria needed in regard to meet the CPT’s criteria especially when admitting their patients to the hospital.   

The CPT codes 99221 – 99223 are set aside for inpatient admission, and the lowest level admission code, 99221(level 1 admit)  requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity;  the 99222 (level II admit)  requires a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity, the 99223 (level III admit)  requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity.  Also within meeting these criteria, all three key components are to be met.  The only difference between a 99222 and a 99223 code is the medical decision making of moderate complexity vs/ high complexity.

As a case in point, In order to bill a 99222  “level II” admission, CPT guidelines require a comprehensive exam to be noted in the clinical documentation of the medical record. 

It is common to see the clinical documentation noted in the record denoting a  comprehensive history, and moderate to high level medical decision making, but the “exam” portion can be very  skimpy. 

As per the 1995 exam guidelines to code/bill a 99222 or a 99223 admission, the clinical documentation must state that greater than 8 body systems or body areas were examined to meet the comprehensive exam requirement (on a multisystem exam).  

As per the 1997 exam guidelines the clinical documentation must state that for the Comprehensive Examination (single specialty)  – should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected.

Unfortunately, the reality is that these examinations are more than likely being performed by the providers, however, coders are finding that clinicians are doing a  poor job of documenting that these exams were performed, even with the many EMR documentation tools at their disposal. 

 However, if these physicians and providers utilize the option of documentation of “Time” in the clinical notes,  they still have to document the care given, but it can be noted that they spent “XX amount of time”  at the bedside and/or on the unit in care of the patient and of that 50% of this time was spent in counseling, and coordination of care of “XXX diagnosis, testing, etc”

From a revenue and denial standpoint, it is frustrating to have an auditor or insurance carrier review the clinical chart and downcode the admission from a  99222/223 to a low level admission 99221 due to skimpy history,  exam, or medical decision notations. 

So the “pearl” of wisdom is to be cognizant of the clinical documentation habits, for the physician providers, which can include macro’s, shortcuts and additional EMR/EHR data based tools.  As coders/billers/managers,  we need to be diligent and educate providers on the usage of time based billing for admissions and other pertinent E&M services. 

Not all CPT E&M services have a time based component that can be utilized to represent the care provided.  Within the CPT codes outlined for usage in an Emergency Department, “Time” is NOT a descriptive component, and all three key components for each CPT code 99281 - 99285 must be denoted within the emergency department patient visit.    The rationale that CPT gives us for this caveat is that emergency services that are typically provided can be hugely variable due to acuity and presenting diagnosis factors. 

The usage of time should not be a totally foreign concept to most providers, as this has been in place in one form or another since1992.  The usage of time as a billing/coding component for providers to use, can get overlooked, or forgotten when in the heat of the moment, or in the day to day busy patient load or high complexity patient demand on the provider.  

Time based clinical documentation does need to be very specific,  The face-to-face time spent in an outpatient or office type setting  includes not only the time the provider spent counseling and coordination of the patients care but has to be rendered face to face with the patient.   Any pre or post time spent ( when patient and provider are not face to face) cannot be included in the time component described in the CPT E&M codes. 

If the provider is providing care for a patient that is on a hospital unit or floor, the intraservice time for these codes is noted or defined as “unit/floor time”  which includes the time present on the patient’s hospital unit and at the patient’s bedside providing services for that patient.   In this setting, this includes time to establish and review the patient’s chart, examine the patient, write clinical notes, documentations,  orders and to communicate with other providers and the patient’s family.   In this hospital setting the pre and post time including time spent off that patient’s floor are NOT to be included in the time component noted in the CPT code descriptors. 

In the descriptors below it outlines the criteria for the 99221, 99222 and 99223 hospital admission codes and how the dime designations are presented.   These times noted in the CPT descriptions are considered a “typical” amount of time spent, however, actual time may vary.

CPT® 99221 is defined by the AMA as:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

CPT® 99222 is defined by the AMA as:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

CPT® 99222 is defined by the AMA as

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.

Clinical documentation of time can be denoted as a cumulative amount, or as a time in/time out notation within the record.  In a best practice, the provider would document both.  

Appropriate time statement examples

·         Time in was 1400,  time out at 1506, I spent 40 minutes of the 66 minutes in the encounter counseling the patient on  their diagnosis  of  “xxxxx” and the remainder of the time was spent obtaining the HPI and examination of the patient.

·         I spent greater than 50% of my 30 minute visit with the patient discussing the options of surgery versus watchful waiting regarding their diagnosis of “xxxxxx”

Inappropriate Time Statement Examples:

·         I had a lengthy discussion with the patient.

·         I spent 20 minutes in supportive counseling.

·         I spent 15 minutes talking about the treatment options.

·         I spent 30 minutes with the patient

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.