Coding tips: Time-based E/M billing

Published on: 
Medical Economics Journal, July 25, 2018 edition, Volume 95, Issue 14

Follow these three tips to avoid denials when reporting time-based E/M codes. 

It may be easier to bill an E/M code based on time alone because physicians don’t need to count bullet points in the E/M guidelines to level a service. However, doing so can also put a practice’s revenue at risk if physicians report time-based E/M codes frequently, says Michael Strong, CPC, bill review technical specialist at SFM Mutual Insurance Company in Bloomington, Minn. These codes should be the exception rather than the rule, and physicians shouldn’t use time-based E/M codes to circumvent proper documentation or medical necessity, he adds. Strong provides these tips to avoid denials:

1. Use time as the controlling factor only when a physician spends more than 50 percent of the visit counseling the patient or coordinating care.

Counseling and coordinating care include the face-to-face time with the patient and/or family member spent obtaining a history, performing an exam, or counseling the patient. They do not include the following services:

  • Administrative tasks for which payers do not reimburse (e.g., documenting in the EHR, dictating, refilling prescriptions, or completing workers’ compensation applications)
  • Arranging for additional services
  • Communicating with other professionals or the patient via written reports and telephone
  • Reviewing records and tests before or after the face-to-face visit

Physicians should clearly document how much time they spent performing the counseling and coordination of care and what they did specifically, says Strong. “If you don’t describe it, the payer doesn’t know whether you met the criteria,” he adds.

2. Choose the code that most accurately describes the services rendered.

For example, one of the following CPT codes might be more applicable than billing a time-based E/M code, says Strong:

  • 99401-99404 (individual preventive medicine counseling and/or risk factor reduction intervention)
  • 99406-99407 (smoking and tobacco use cessation counseling)
  • 99408-99409 (alcohol and/or substance [other than tobacco] abuse counseling)
  • 99411-99412 (group preventive medicine counseling and/or risk factor reduction intervention)

3. Bill psychotherapy separately from the E/M service.

When physicians perform psychotherapy in addition to an E/M service, they should report the E/M service as well as an add-on code for the psychotherapy (i.e., 90833, 9036, or 90838), rather than using time as the controlling factor for the E/M code and forgoing the psychotherapy code, says Strong. Physicians also can’t use time-based billing for the E/M service when they report it with a psychotherapy add-on code. Instead, select the E/M code based on the history, exam, and medical-decision making, he adds.