Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
Time! Not just any time but “Total time”. With the 2023 Evaluation and Management changes just weeks away, it is only fitting to discuss and analyze what we saw during the daily coding of charts and audits after the 2021 E/M Revisions.
In implementing the 2021 Evaluation and Management guidelines, providers were going from billing “time” they spent face-to-face with the patient to both face-to-face and non-face-to-face time on the encounter date. Many have noted during audits that various organizations and private practices lacked the “total time.” Some EMRs may have had a code range, and providers thought selecting the check box was sufficient enough to bypass entering the total time. Some physicians also thought selecting the code range on a superbill was sufficient when documenting time, so no time was recorded in the progress note/documentation. Unfortunately, other providers did not know there was a change and reported 50% counseling coordination of care instead of total time.
It is imperative that when moving forward to the implementation and education of 2023 Evaluation and Management changes, providers have been educated on guidelines changes, documentation requirements and accurate reporting of total time.
Suppose a provider and other qualified healthcare professionals utilize total time (on the service date) instead of Medical Decision Making. In that case, that total time should be documented in the record. For example, a provider sees an established patient in the office and decides to use total time level 4; the range is 30-39 minutes; the provider would not select or write the range. Instead, there should be an exact “35 minutes” of total time documented.
Reviewing the 2023 changes, we also note that the inpatient setting, nursing home, and residential facilities do not include a “range” but a “total time.”
If on the same day as an E/M, a provider provides separately reportable services (reporting/billing a CPT code), that time should not be counted towards the total time. I suggest a statement in the note/documentation stating that “total time spent was ___, which included ______ (work done listed) but excluded any separately performed services. This would help avoid any ambiguity in the documentation. Remember to apply the appropriate modifier (25) if a significant and separately identifiable E/M service was performed with a separately reportable service.
Another change we saw from the initial 2021 Evaluation and Management revision on January 1, 2022, was CMS Teaching Physicians, Interns & Residents Guidelines clarifying resident time in the Office and outpatient services. Initially, total time included resident time in the primary care setting in 2021, but CMS made a clarification after a year of review. “When selecting the visit level, only count the time the teaching physician spent doing qualifying activities listed by CPT (with or without direct patient contact on the encounter date), including the teaching time present when the resident does those activities. Under the Primary Care Exception, you can’t use the time to select the visit level. You may only use Medical Decision Making (MDM) to choose the E/M visit level.
Per AMA revised 2023 guidelines, total time “includes both the face-to-face time with the patient and family/caregiver and non-face-to-face time personally spent by the physician and other qualified provides care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). This includes time regardless of the location of the physician or other qualified healthcare professional (e.g. the inpatient unit or the outpatient office). It does not include any time spent in the performance of another separately reported service (s)”.
What does time include?
Providers also want to ensure that documentation supports the work done during the time, e.g. If you reviewed external records documented, counseling and coordination of care and ordered medication, it should be identified in the progress note/documentation. This would ensure that coders and auditors are aware of why 60 minutes of the total time is documented, but instead, the note needs to support the work done.
Per AMA revised guidelines, physician or other qualified health care professional time includes the following activities, when performed:
- preparing to see the patient (e.g., review of tests)
- obtaining and reviewing the separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- ordering medications, tests, or procedures
- referring and communicating with other health care professionals (when not separately reported)
- documenting clinical information in the electronic or other health records
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- care coordination (not separately reported)
Time does not include the following:
- the performance of other services that are reported separately
- teaching that is general and not limited to the discussion that is required for the management of a specific patient
Total time on the service date does not include any work done the day or days before the service date and cannot be counted as total time on the visit date.
Providers and other qualified healthcare workers spend much time with patients face to face and provide no face-to-face work, such as care coordination. All the time spent on the date of service performing the work listed above should be calculated and reported. If providers spend additional time that is greater than the maximum time requirement, they will want to see how much they spent and if they can report prolonged codes.
Prolonged codes are reported in 15 minutes increments. According to AMA, “Prolonged total time is 15 minutes beyond the time required to report the highest-level primary service.” Reviewing the coding guidelines for reporting prolonged codes and knowing payor policies is essential. AMA requirements for reporting prolonged codes differ from the CMS requirement in counting the “maximum time.” For example, AMA states that to report the initial unit of 99417 for a new patient encounter (99205), at least 15 minutes must be accumulated beyond 60 minutes (i.e., 75 minutes) on the date of the encounter. For CMS to report G2212, it calculates the time once you meet the maximum time of 99205 (74 mins) plus an additional 15 minutes total time (i.e., 89 minutes); anything less cannot be reported as prolonged time.
Example of Prolong time reported in Office and Outpatient Services:
|E/M Code||Time Range||AMA CPT Prolong Time 99417||CMS Prolong Time G2212|
|99205||60-74 min||75-89 min||89-103 min|
|99215||40-54 min||55-69 min||69-83 min|
Per AMA shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient and/or counseling, educating, communicating results to the patient/family/caregiver on the date of the encounter is summed to define total time.
CMS has postponed reporting time as the substantive portion for split share visits until January 1, 2024. In CMS’s recent article, Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule, the substantive portion for the calendar year 2023 (CY) consists of History, Performing Physical Exams, Medical Decision Making or Time (more than half of the total time spent by the practitioner who bills the visit). It will be imperative for educators to communicate with physicians, coders, and billers about the 2023 E/M changes, review the guidelines when reporting total time in each service area, and conduct an audit and chart reviews within the first few weeks and months to ensure providers are documenting and reporting time accurately. The best thing is that providers get to choose whichever option works best for them; whether it is MDM or Total Time and which one captures all the work done in its entirety while noting the complexity of their patients. Continued education will be vital for success.
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