Understanding proper use of time-based coding and billing

Q: Our group has a question regarding office billing as it pertains to billing levels and the expected time allotment given to each code. If you bill a 99214, are you expected to spend 25 minutes of time coordinating care for the patient?

A: It’s common to get different answers regarding time-based coding because it is one of the least-understood elements of Evaluation and Management (E/M) service coding.  While most E/M patient encounters are coded using the components, history, physical examination, and medical decision-making, the level of service selected for some encounters will best be reflected by using time as the key component.

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For example, the Current Procedural Terminology description for 99214 includes the verbiage, “Typically, 25 minutes are spent face-to-face with the patient and/or family.”  This means that the physician or non-physician practitioner would spend a total of approximately 25 minutes face-to-face with the patient when billing a 99214.

It is important to note that not all codes have typical times (e.g., domicilliary care). In such cases, time may not be used to select the code level. When selecting time, the provider must have spent a time closest to the code selected. For example, 99214 has a typical time of 25 minutes, and 99213 has a typical time of 15 minutes. If the face-to-face office time is 21 minutes, select code 99214 since it’s more than half of the time difference.

Unless there is evidence that the provider has inappropriate billing patterns (i.e., billing more services than possible in one day), insurance carriers normally will not question the time spent if the history, exam and medical decision-making elements are met.

The answer to the reader’s question was provided by Renee Dowling, a coding and billing consultant with VEI Consulting in Indianapolis, Indiana. Send your coding and billing questions to medec@advanstar.com.