Monday Nov 23, 2020
Tips for using total time to code E/M office visits in 2021
Editor's note: In its 2021 Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.
Outpatient E/M coding and documentation reforms that take effect Jan. 1 will allow physicians and other qualified health professionals (QHPs) to code office visits based solely on total time.
It pays to get familiar with the following table before then, and it may be worthwhile to attach it to your monitor or place it on your desk.
|Visit level||New patient code||New patient time||Established patient code||Established patient time|
All times in minutes
For longer visits there is a prolonged visit code, 99417, that should be reported with 99205/99215 for every 15 minutes that total time exceeds the ranges for those codes. CMS, however, has decided to allow physicians and other qualified health care professional to bill for prolonged services only when they have exceeded the maximum time for a Level 5 visit by 15 minutes or more (at least 69 minutes for an established patient and 89 minutes for a new patient), rather than the minimum time. Because of the discrepancy, Medicare has its own code, G2212, for reporting prolonged services.
Total time includes all of the time the physician or QHP spend on that visit on the date of service. That means it includes prepping for the visit (e.g. chart review) and anything done after the visit (e.g. calling other clinicians and ordering tests or procedures) after the face-to-face portion of the visit. But it does not include staff time or time spent by the physician or QHP outside the date of the visit.
Here are some tips for coding based on time, and an office visit example.
Time tracking tips
Delaying the completion of your notes is not usually recommended. But some cases lend themselves to this. If the record review will take extended period, it might be worthwhile to prioritize doing that work on the visit date, if that fits into your workflow. If you anticipate discussing a case with another clinician (or independently interpreting a test) and that time will change your visit level, it may be appropriate to delay signing off on that record.
Keeping track of time is burdensome, leading many of us to forego time-based codes. But those minutes can add up. Some EHRs have timers that automatically track when you’re logged in to a patient's chart, which is imperfect, but helpful. If your system has this feature, make sure the EHR chart is open while you’re reviewing records (and take some notes about that review in the chart) before the visit, and make sure it’s open during the visit as well.
It's also a lot easier if you have the chart open during phone calls. You can add notes during or right after the call summarizing your time and discussion. It is not reasonable to expect that you have a timer logging your every movement in case you need it for coding. Small increments (1-2 minutes) are difficult to track and often don’t’ seem worth the effort to keep up with, so admittedly are easy to "lose." But if you end up on a phone conversation without the EHR tracker going, it's often worth glancing at the call time on your phone and recording that time as well.
If you make a good faith estimate of the time spent on behalf of a patient on the date of the visit and it lands close to the point where it crosses over to the next level and a higher charge, I would err on the side of caution and choose the lower level. But unless you consistently and frequently code 99215 (time range 40-54 min) with an estimated total time of 40 minutes, this is not likely to be an issue.
Some common tasks may be physically impossible for you to complete in less than a certain amount of time, which makes it easier to record. For example, my state requires physicians to check the Prescription Drug Monitoring Program (PDMP) when we prescribe controlled substances. While it sometimes takes longer, this task is never less than two minutes for me. Other recurrent tasks that may have a specific "base time" for you might include specific types of phone calls (e.g. pharmacy), certain referral tasks, or specific documentation activities (e.g. Family Medical Leave Act paperwork).
Some things just don't lend themselves to time tracking, like results review. But if your total time is going up toward the threshold for a higher level visit, then by all means, add in that couple minutes.
A 76-year-old established patient with mild to moderate dementia, who lives in an assisted living facility, presents with confusion related to her medication regimen. She also has diabetes and hypertension. Pill counts are performed during the visit and records from an urgent care center are reviewed. The physician also reviews medication pick-up history with the pharmacist. In addition to periodic urgent care visits with medication changes, the physician discovers erratic refill patterns. The physician has a phone call with the patient’s family member who has power of attorney (POA) and helps with a pill planner. They discuss medication adjustments, and a plan to shift the patient’s medication administration to “supervised.”
Here's how the time for each activity could break down, and how the physician or QHP could track it.
|Pre-visit planning, chart review, and face-to-face encounter||18 (tracked by EHR)|
|Review of urgent care records (receicved after visit, same day), with brief summary noted in EHR||6 (tracked by EHR)|
|Discussion of medications with pharmacy technician||11 (recorded by phone)|
|Phone call with family member (POA)||13 (recorded by phone)|
|Coordination with office staff for med adjustments and bubble packing||5 (estimated)|
|Final documentation of visit||4 (tracked by EHR)|
|Total time||52 (code 99215)|
You are not required to split out the total time into its various segments like this, but it may prove useful in the event of an audit. Some of the activities listed could be anticipated following the visit (e.g., the phone calls to the pharmacist and POA). It should be clear relatively early in this encounter that at least the 30-minute threshold for 99214 would be met, and so it would be worthwhile to start tracking the time.
Prior to 2021, only the face-to-face time with the patient can be considered for time-based coding. Using this example, that would be less than 18 minutes (assuming chart review was performed before the face-to-face time). Although the other activities are important, they cannot be counted toward “time” until the new rules take effect. Getting into the mindset that everything you do for that patient on that day "counts," as of Jan. 1, will make you better prepared to code using time, and more diligent about tracking those minutes.
— Samuel L. Church, MD, MPH, CPC, CRC, FAAFP
Northeast Georgia Medical Center Family Medicine Residency, Core Faculty
AAFP Advisor, AMA CPT Editorial Panel
Posted at 11:45PM Nov 23, 2020 by FPM Editors