Medical Billing Tip: Consider Time-Based Coding for E/M

October 16, 2020 by Antonio Arias, MBA, CHBME

Topics: Medical Billing

Sometimes a visit goes long – an extra five or ten minutes – and it throws off your morning schedule. Other times, a visit goes way too long – an extra 20, 40, or even 60 minutes – and it practically wrecks your entire day’s schedule.

As a medical billing company we hear from providers that are hesitant to charge for that extra time, especially if it was spent providing consultative services or addressing a patient’s personal or emotional issues. In certain circumstances, however, it is appropriate to bill for extra time using either a higher level evaluation and management (E/M) code or prolonged service codes.

Evaluation & Management: The ‘Three Cs’

E/M codes have many applications, but utilizing them for time spent with patients is about Counseling and/or Coordination of Care. Many discussions fall under the umbrella of the ‘three cs’: medication or treatment options and their associated risks, lifestyle changes, diagnostic testing orders or results, patient education, referrals, and more.

If more than 50% of the provider's face-to-face visit time with a patient is spent in counseling or coordination of care, E/M codes 99201-99215 can be applied. The key, however, is documentation.

Coders should not use E/M codes to bill for time unless the provider documents all of the following information:

  • Total time of visit
  • Percentage of visit spent in counseling/coordination of care
  • Topic or nature of the counseling/coordination of care

In addition to the 50% threshold, the visit must exceed standard average visit time to use an E/M code to bill for time. An example might be when the provider codes a 99214 and spends 30 minutes with an established patient and 20 minutes of that time was for counseling .  

Prolonged Services: The 60-30 Rule

Prolonged physician services can be billed in the rare instance in which a provider spends at least one hour of face-to-face time with the patient beyond the typical E/M visit length. In the outpatient setting, the CPT code for this is 99345; inpatient is 99356. (The appropriate companion E/M code must be used at the same time as 99345 or 99356 in order for prolonged services to be payable.)

In the occasion that a visit goes an hour-and-a-half longer than it should, there are codes for that, too. Each additional 30 minutes of face-to-face patient time that follows the first ‘prolonged services’ hour can be billed with CPT code 99355 (outpatient) or 99357 (inpatient). Document visits diligently and apply E/M and prolonged services codes with care to avoid denials. 

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