If the additional time that you are spending with your patients is for counseling or coordination of care, you can bill evaluation and management codes based on time. Here's how.
Q: I’m getting burned a lot from not billing for extra time spent with patients. What codes are available to bill above and beyond time spent?
A: If the additional time that you are spending with your patients is for counseling and/or coordination of care, you can bill evaluation and management (E/M) (99201-99215) codes based on time. In order to do this, you need to document the following information:
Time may be estimated, but that estimate, along with the duration of the visit, must be recorded when time is used for the selection of the level of a service that predominantly involves coordination of care or counseling. Also, be sure to include counseling/coordination of care detail specific to that patient’s plan of care. Examples include discussing changes in the patient’s medical condition, lifestyle changes, new medications and new testing.
This also includes discussing referrals to other providers and ordering of tests if it meets the time criteria.
Another tool is prolonged service codes. In order to bill these codes, you need to provide at least one hour of face-to-face patient contact beyond the usual E/M service. The time for usual service refers to the typical/average time associated with the companion E/M service as noted in the CPT code.
Prolonged physician services (CPT code 99354) in the office or other outpatient setting with direct face-to-face patient contact which require one hour beyond the usual service are payable when billed on the same day by the same physician or qualified non-physician practitioner (NPP) as the companion evaluation and management codes. Each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99355.
To determine when you should bill a higher-level E/M versus prolonged services-or when both are appropriate-follow these tips:
First, choose the code in the category based on the code’s typical time for counseling-dominated visits.
For example: A physician spends 25 minutes managing an established patient’s chronic conditions and an additional 30 minutes counseling the patient. Since the physician spent more than half the visit counseling, he or she can bill based on time. The total time of the visit is 55 minutes, which is only 15 minutes longer than the average time for 99215. Since the time doesn’t meet the 30-minute minimum threshold, a prolonged service code cannot be billed in addition to the 99215.
The counseling for this scenario includes discussing with the patient or family the diagnostic test results, prognosis, risks and benefits of the treatment options, instructions for treatment or follow-up, the importance of compliance with treatment, risk factor reduction and education.
Second, use an E/M and prolonged services code when the physician spends 70 minutes or more on an E/M visit and counseling.
An example of this is when a provider spends 30 minutes performing the E/M service, plus 40 minutes counseling. Since more than half of the visit was spent counseling, the provider could bill 99215. Also, the additional 30 minutes spent with the patient qualifies to bill 99354. See the accompanying table for office/outpatient prolonged services threshold times.
Remember, when you are billing your E/M based on time, don’t use prolonged services codes unless you’ve reached the top code in the E/M category.
Third, select the E/M based on typical time and add a prolonged services code when the extra time is spent monitoring, not counseling.
If a provider performed the elements (i.e., history, exam, medical decision making) to meet a 99213, then gave the patient medicine and wanted to monitor its effects for 30 minutes, 99213 plus 99354 could be billed. When the visit is not based on counseling, you should not move up the level of the base code, but instead you should bill the appropriate level of E/M plus the prolonged services code.
Fourth, know the thresholds for the prolonged services codes. For 99354, you can bill the code after 30 minutes. For 99355, the prolonged service should total at least 75 additional minutes beyond the E/M service being billed.
Finally, require providers to clearly differentiate in the documentation the amount of time spent on counseling or monitoring separately from the total length of the service.
Even when a provider documents the full time of the visit, if the time spent counseling isn’t documented, the provider can’t base the E/M on time and cannot bill prolonged services. Make sure your providers list how much time they spent on counseling topics.
The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your coding and billing questions to firstname.lastname@example.org.