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Time Based Services

  1. Please clarify documentation requirements for time spent in performing prolonged services.

    Answer:
    As with any time-based service, clock time (1:00 pm-1:50 pm) is the preferred method of documentation, although “50 minutes of care” is acceptable. Updated 8/29/2017
     
  2. Please clarify the use of time spent in documentation; can this time be counted toward time spent performing a behavioral health service (G0502-G0504)?

    Answer:
    Time spent in documentation of a service is never allowable as time spent in fulfilling the time requirement for a time-based service. This includes the behavioral health Integration code.

    Time-based services represent face-to-face time with the patient, or time spent in direct coordination of the patient’s care, or non face-to-face time in prolonged service, when all other requirements are met.

    Documentation time for each encounter is considered an administrative factor and not included as time spent in performing the service. Updated 8/29/2017
     
  3. In the office setting, the counseling is performed F2F with the patient and/or family. Does the coordination of care piece also need to be done in the presence of the patient?

    Answer:
    In the office environment, all elements of an E&M service, including counseling and coordination of care, require F2F presence with the patient. When additional telephone time spent after the visit meets or exceeds 31 minutes, the time may be billable under the non-F2F prolonged service codes (99358-99359). Updated 8/29/2017
     
  4. When billing based on time can their statement start “I spent 60 minutes with the patient greater than 50% spent in counseling and/or coordination of care…”? Or must it be clearly separated such as “I spent 60 minutes with the patient greater that 50% spent in counseling and coordination of care…..” or “I spent 60 minutes with the patient greater than 50% spend in counseling….”?

    Answer:
    Any of the examples quoted here are adequate. Updated 8/29/2017
     
  5. Do you accept CMS' 1995 and 1997 guidelines for coding a service?

    Answer:
    Both CMS guidelines (1995 and 1997) are acceptable. Updated 6/9/2017
     
  6. What is the requirement for billing based on time?

    Answer:
    The level of coding is based on time for services in which 50% or more of the visit time was spent in counseling and/or coordination of care. In these instances, the level of coding is selected based on the suggested time noted in the CPT definition of the code. Updated 6/9/2017
     
  7. Is the statement "I spent 35 mins in care today“ considered valid documentation for 99233, if the coding is based on time?

    Answer:
    If time has been used in establishing a coding level of 99233, based on 50% or more time in the visit spent on counseling or coordination of care, the note must reflect the content of the discussion in order to support the medical necessity of the visit and the time spent. Updated 6/9/2017
     
  8. Please clarify how to code a time based established patient visit of 20 minutes. Is 99213 or 99214 appropriate? Are there rules about rounding up or down when billing is based on time?

    Answer:
    Billing based on time is only appropriate for E&M visits during which 50% or more of the time was spent on counseling and/or coordination of care. The suggested CPT timeframe for 99213 is 15 minutes and 99214 is 25 minutes. If the provider spent and documented 20 minutes in face to face care, the appropriate code would be 99213. Updated 6/9/2017
     
  9. After an initial visit with a surgeon, during which a decision is made for surgery, can a subsequent visit with the surgeon be payable, primarily to discuss additional patient concerns and questions?

    Answer:
    A subsequent visit may be medically necessary in responding to the patient’s concerns. We would expect to see this situation associated with upcoming major, complicated surgical events.

    When a visit includes 50% or more time spent in counseling, the visit level is set by time correlative to the suggested CPT timeframes. If this patient returns to the office for a visit spent primarily on counseling, that visit should be level-set based on time spent, and the time carefully documented in the medical record. Updated 6/9/2017
     
  10. If a billing based on time statement is found within the documentation should time then be the controlling factor for billing or can we bill whatever is more advantageous (Billing based on time or elements)?

    Answer:
    If a provider’s note indicates a clear preference to bill the service based on time, NGS would expect a level of service correlative with the suggested CPT timeframe.

    The presence of a time notation alone does not mandate that the coding be based on time; there are instances in which the level of detail for history, examination and MDM will bring the service to a higher level of coding than the time alone, and this is permissible.

    If, however a visit does not include key required elements (history, exam and MDM) and is based on >50% of time counseling, then that service must be coded based on documented time spent during the encounter. Updated 6/9/2017
     
  11. What does NGS look for if a provider bills for an E&M code using time as the determinant for the level of coding?  Does the provider have to document the specific topics addressed in the counseling?

    Answer:
    When counseling is the predominant service during an E&M encounter, the medical record needs to reflect the specific time spent (e.g., “45 minutes” or “1pm to 1:45 pm”) and the topic(s) being discussed. Please note that time spent should correlate to the nature of the counseling topic. For example, counseling on new diagnostic findings and treatment options would naturally require a lengthier discussion than counseling on smoking cessation, medication adjustment or weight loss. Updated 6/9/2017
     
  12. How is medical necessity determined when the time is used to set an E&M level during a visit in which counseling exceeds 50% of the time spent?

    Answer:
    Time can be used to determine an E&M level when greater than 50% of a visit is spent in counseling the patient or coordinating the patient’s care. The actual time spent must correlate to the nature of the counseling, e.g., the topics discussed and their relative degree of complexity and potential impact to the patient.

    The level of coding is selected based on the CPT estimated timeframe for the E&M level. When the documentation does not support the need for the documented time, the service may be down-coded upon review. Of course, the actual time spent must be recorded in the medical record.

    Example: Discussion of a newly diagnosed malignancy with multiple treatment options may well be justified at 60 minutes duration, while discussion of newly diagnosed hypertension and the need for dietary sodium restriction would probably not support 60 minutes duration. Updated 6/9/2017
     
  13. When counseling and coordination of care do not predominate in time spent with the patient, does a visit need to meet the suggested time referenced in the CPT manual?

    For example, if a visit is 20 minutes and the documentation of a 99214 is sufficient to justify the service, can CPT code 99214 be billed even though the CPT manual reads “typically 25 minutes are spent face-to-face with the patient and/or family member”?

    Answer:
    Timeframes referenced in the CPT manual are “suggested” timeframes, and visits in which counseling or coordination of care are not the basis for coding may qualify at a given coding level based on documented details of history, examination and medical decision making. Updated 6/9/2017
     
  14. Please provide examples of valid time statements across categories (specifically-inpatient E&M services including discharge, initial, subsequent, consult and office/outpatient).

    Answer:
    Time statements can be documented as “9:00am to 9:40am” (preferred) or “spent 40 minutes with patient”. Updated 6/9/2017
     
  15. When selecting the E&M level of service based on duration of coordination of care or counseling would documenting “majority” be sufficient for an indication of more than 50%? Also from the scenario would documenting “time spent in discussion, treatment planning and answering questions” support the description of the coordination of care or counseling? If it is not sufficient, what needs to be documented to support the description of the coordination of care or counseling?

    Answer:
    We would interpret “majority” to mean greater than 50% of the time spent, but would advise the provider to specify “more than 50%” since it leaves no room for misinterpretation. In addition, the provider needs to include general details of the counseling topic, since the topic supports medical necessity for the service and also allows for a correlation to the duration of time spent. Updated 6/9/2017

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