If your practice isn’t using time-based codes correctly, you are leaving money on the table. Or worse, opening yourself up for massive fines per misuse.
The truth is, most coders and their physicians steer clear of these codes out of fear of the consequences of getting it wrong. But, there’s no need to avoid these codes if you follow a few simple rules.
According to CMS, with Evaluation and Management services when “… counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.”
E/M IS NOT THE ONLY TIME-BASED CODE
If fear of audits has you running scared from these codes, try these tips to get the reimbursement you deserve without the added anxiety.
- Identify when time rules. Consider how your physician’s time is being spent during an encounter. Is it a routine evaluation or is he or she spending considerable time counseling the patient on their condition? For example, if your provider is spending more than 50% of the visit discussing diet and exercise with a diabetic patient, you could justify a higher level of service, which leads to a higher reimbursable rate.
- Non-face to face time doesn’t count. According to CMS, time spent coordinating care has been averaged into the time listed for each code and should not be counted separately for most This includes the time your physician spends talking with other providers about a patient’s care, as well as, reviewing medical records and lab results. Critical care codes 99291 and 99292 are exceptions. These codes do allow you to capture floor or unit time in the total duration of patient care.
- Capture prolonged services with codes 99354 and 99355. If you work in an office or other outpatient setting, use the add-on code 99354 to capture service times that extend an hour beyond the time listed for the primary code. Use code 99355 for each additional 30 minutes. But, remember that the service must be provided by the same provider on the same day as the primary code. For inpatient or observation settings, use 99356 for the first hour and 99357 for each additional 30 minutes.
- Prolonged Clinical Staff time. If your clinical staff, by your order, spends time beyond the typical service time face-to-face with the patient, bill 99415 for the first hour.
- Don’t forget to document. The key to audit-proofing your time-based coding is to have the documentation to back it up. Documentation requirements are not the same for all time-based codes. Make sure your physicians are noting the activities of the visit and why extended time was needed by themselves or their clinical staff. Denoting time is always required for time-based-codes to fly, but in some cases, as in E/M, there may be more required. (Check out this training session for proven time-based coding documentation strategies).
Properly using time-based codes, and documenting them appropriately, can be a boon for your bottom line and prevent unwanted attention from the auditor. Remember these tips to keep your time-based coding on the straight and narrow.
- Don’t be afraid to use time-based codes. These codes are designed to provide your physicians the reimbursement they deserve for extended service times.
- Educate your physicians. Making sure your providers are educated on using time-based codes is essential to both audit-proofing your coding and maximizing your reimbursement.
- Remember to use prolonged services codes. Use prolonged services codes where your physician or clinical staff by the order of the physician spends face-to-face time with the patient that exceeds an hour.
For more information on E/M and time-based coding check out these training sessions from Coding Leader:
- Learn how to identify when the clock starts ticking in Time-Based Coding: Get Paid More with coding expert Michele L. Davis, CPC, CPMA, CRC, CPC-I.
- Discover how you can receive more of the reimbursement you deserve for consultations in Consults: Get Paid More, Cut Denials with nationally recognized author, lecturer, and healthcare consultant Maxine Lewis, CMM, CPC, CPC-I, CCS-P.
- Get strategies to reduce your E/M error rate and maximize reimbursement in E/M Coding: Unmatched Expert Tactics to Boost Your Pay-Up with medical coding, billing, and healthcare compliance expert Marsha S. Diamond, CPC, CPC-H, CCS, CPMA.