Without a thorough understanding of the guidelines, calculating time may land you in hot water.
When time is the controlling factor in a patient’s visit, be sure to capture the appropriate time-based service code.
Per CPT®, unless there are code or code-range-specific guidelines, parenthetical instructions, or code descriptors to the contrary, the following standards apply to time measurement:
A unit of time is attained when the midpoint is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and 60 minutes). A second hour is attained when 91 minutes have elapsed.
When codes are ranked in sequential typical times, and the actual time is between two typical times, use the code with the typical time closest to the actual time.
Avoid Time Traps when Using Rule No. 2
Let’s look at psychotherapy codes to illustrate the second rule.
90832 Psychotherapy, 30 minutes with patient
90834 Psychotherapy, 45 minutes with patient
In this example, the actual psychotherapy time with the patient is 37 minutes.
Only 16 minutes is needed to report 90832 (past the midpoint of zero and 30 minutes); however, do not fall into the trap of thinking that 23 minutes is needed to report 90834 (because 23 minutes is the midpoint between zero and 45 minutes). This is an example of sequential times. Per CPT® instructions, when codes are ranked in sequential typical times, and the actual time is between two typical times, use the code with the typical time closest to the actual time. Here’s how to do the math:
90832: 30 minutes
Actual Time: 37 minutes
Difference: 7 minutes
90834: 45 minutes
Actual Time: 37 minutes
Difference: 8 minutes
In this example, the actual time is closer to 90832 (7-minute difference) than 90834 (8-minute difference); making 90832 the more appropriate code.
Meet Thresholds for Time-based E/M Services
Let’s look at some other scenarios to determine how to select an evaluation and management (E/M) code based on counseling and coordination of care time.
A nurse practitioner (NP) spends a total of 30 minutes with a patient. Twenty minutes is spent counseling the patient on his uncontrolled hypertension and end-stage renal disease, noncompliance with prescription medications, dialysis, and home blood pressure monitoring.
To report an E/M visit based on counseling/coordination of care time, more than 50 percent of the total encounter time must be spent counseling the patient or coordinating care. To determine how much counseling/coordination of care time exceeds the 50 percent threshold, however, first determine which E/M code is applicable.
In this scenario, the total encounter time of 30 minutes is closer to 99214 than 99213:
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
The NP spent 20 minutes counseling the patient, which is more than 50 percent of the 25 minutes needed for procedure code 99214. As such, it is appropriate to report 99214.
A physician assistant (PA) spends a total of 20 minutes with a patient. Twelve minutes is spent counseling the patient on her type 2 diabetes with peripheral neuropathy, and the importance of foot hygiene.
To calculate how much counseling/coordination of care time exceeds the 50 percent threshold, first determine which E/M code is applicable. In this scenario, the total encounter time of 20 minutes falls equidistant between 99213 (typical time 15 minutes) and 99214 (typical time 25 minutes). When the total encounter time is equidistant from two codes, revert to the counseling/coordination of care time.
In this example, 12 minutes were spent counseling the patient. Twelve minutes is more than 50 percent of the 15 minutes needed for procedure code 99213, and less than 50 percent of the 25 minutes needed for procedure code 99214. Procedure code 99213 is appropriate. At least 13 minutes of counseling/coordination of care time would be needed to exceed the 50 percent threshold and bill procedure code 99214.
Chart Critical Care Services
CPT® provides a chart for critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and +99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). Use this chart to determine which code(s) is appropriate for the total critical care time on a given day.
Example: Dr. Smith spends 38 minutes rendering critical care in the morning; 22 minutes rendering critical care in the afternoon; and 45 minutes in the evening (all for the same patient). The time spent by Dr. Smith throughout the day can be added together and reported as a single claim, even though the time is not continuous. In this case, Dr. Smith spent a total of 105 minutes of critical care time; therefore, he can report 99291 x 1 for the first hour and 99292 x 2 for the remaining time, per the chart in CPT®.
Time spent performing separately reportable procedures or services should not be included in the time reported as critical care.
Example: A patient involved in a fire at home suffers multiple third-degree burns of the face, neck, and arms. The patient also suffers from smoke inhalation. The critical care time is 90 minutes, during which the patient is placed on a ventilator. In this case, procedure codes 99291 and 99292 can be billed for the total critical care time, which includes the time spent inserting and regulating the ventilation device.
Procedure code 94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day should not be billed when rendered during the critical period by the same physician performing the critical care. As such, the time spent providing ventilation management does not have to be separately documented because the procedure is not separately reported.
Example: A hospital inpatient goes into cardiac arrest and a “code blue” is called. The intensivist performs cardiopulmonary resuscitation (CPR) on the patient (92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)) and documents he spent 35 minutes rendering critical care.
It is best to document critical care and procedure times separately. This ensures the reportable critical care time is clearly documented.
In this case, it’s not clear from the documentation whether the 35 minutes spent rendering critical care includes the time spent performing the CPR so the physician is queried. The query yields that the physician spent 25 minutes rendering critical care and an additional 10 minutes performing CPR. The physician amends the medical record accordingly.
Because only 25 minutes of critical care time was spent, the threshold for reporting the first hour of critical care (30 minutes) was not met, and a critical care code cannot be reported.
Per CPT®, report the appropriate E/M code based on patient status and location. If the documentation supports a significant, separately identifiable E/M service, report the E/M service and the CPR code. Append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the E/M service. If a significant, separately identifiable E/M service is not supported in the documentation, report only the CPR code.