E/M office visit coding series: Tips for time-based coding

The 2021 E/M office visit coding changes allow physicians to code visits based solely on total time, which is defined as the entire time you spent caring for the patient on the date of the visit. It includes your time before the visit reviewing the chart, the actual face-to-face visit with the patient, and all the time you spend after the visit on documentation, reviewing studies, calling the patient or family, etc. — as long as you do it before midnight on the date of service. It does not include time you spend on other dates, time you spend doing procedures that are separately billed, or time your nurses or other staff spend.

For established patients, it may be helpful to remember what I call the “30/40 minute rule”: Level 4 visits start at 30 minutes, and level 5 visits start at 40 minutes. (For more time-based coding tips, see this previous “Getting Paid” post.)

Documentation tips

Documentation is important if you are going to base your coding on time. Rather than just writing “Total time spent was XX minutes,” it’s useful to explain what was included in the time, especially now that patients have access to your notes. They may not understand that the time you’ve listed includes more than just the face-to-face portion of the visit. Here’s an example of a well-explained note: “Total time spent caring for the patient today was XX minutes. This includes time spent before the visit reviewing the chart, time spent during the visit, and time spent after the visit on documentation, etc.”

A little extra explanation may also be useful in case of an audit. For example, if you did a procedure during a visit and billed for it separately, you might want to add, “Time excludes procedure time” just to make sure there’s no confusion about that.

Take care with EHR time calculators

EHR time calculators that document the time a patient’s chart is open can be helpful if you’re using time for coding. But relying on them too much can cause problems. If you don’t remember to open the chart as soon as you enter the room and keep it open for the entire visit, it’s not going to accurately reflect the time you actually spent. If you can access the chart by smartphone as well as computer, make sure your EHR tracks time on both devices or, again, you will have an undercount.

Over-reliance on time calculators could also cause you to overstate your total time if your EHR double-counts time when the chart is open in your office and in the exam room simultaneously, or if it falsely counts time when the patient’s chart is tabbed but not opened.

Long visits (prolonged services)

Unfortunately, depending on the payer, there are currently different prolonged services codes, with different time ranges, for visits that exceed level 5 in total time. Medicare and some private insurance companies use G2212, which is for established patient visits of 69 minutes or more and new patient visits of 89 minutes or more. Other insurers use CPT code 99417, which is for established patient visits of 55 minutes or more and new patient visits of 75 minutes or more. With both codes, prolonged services are billed in 15-minute increments and pay 0.6 work Relative Value Units for each 15 minutes. Below is a chart you can quickly reference for time-based coding, including prolonged services.

— Keith W. Millette, MD, FAAFP, RPH

Posted on Oct. 31, 2022