It is not unusual for rheumatologists to spend significant time during an office visit reviewing new and/or existing problems, modifying medications, counseling, and coordinating care—but is this additional time reimbursable?
For each evaluation and management (E/M) visit, time is the determining factor in selecting the most appropriate code level if the visit does not meet the standard specifications for the history, examination, and medical decision-making elements.
Time is defined in three different ways:
- Face-to-face time happens when the physician meets directly with the patient or family and applies to in-office and other outpatient visits.
- Floor/unit time is when the physician is physically present on the patient’s hospital floor or unit rendering bedside services to the patient. This includes time spent with the patient and working on the patient’s chart or discussing the care with other health professionals. Services for the floor/unit time include hospital observation services, inpatient hospital care, initial and follow-up hospital consultations, and nursing facility services.
- Non–face-to-face time (or pre- and post-encounter time) occurs when the physician performs work related to the patient visit before or after the face-to-face time or floor/unit time with that patient. The responsibilities include obtaining records and test results, arranging for additional services, and communicating with other healthcare providers and/or the patient outside of a face-to-face encounter or time on the floor/unit.
The Current Procedural Terminology (CPT) manual lists the average amount of time typically involved in each E/M code. For example, a patient visit for 99204 averages 45 minutes of the physician’s time and a 99213 visit averages 15 minutes.
CPT coding guidelines indicate that if a physician spends more than 50% of a visit face to face with the patient and/or family coordinating care or counseling, then time may be the determining factor to qualify for a higher level of E/M service. It is critical to have clear and succinct documentation in the medical record of the visit if time will be used as the determining factor of a higher E/M level. A new paragraph must be included documenting what was discussed separately from the history, examination, and medical decision-making elements.
Time plays an important role in the selection of the most appropriate code for services beyond the normal scope of work. Documenting time spent on a patient can be financially rewarding.
In addition to using time as the qualifying factor for a higher E/M level, CPT also has face-to-face and non–face-to-face prolonged time codes that can be billed in addition to an E/M code if time spent extends at least 30 minutes beyond the typical amount of time allotted for that visit. The CPT codes for face-to-face prolonged visits are 99354–99357 and these are add-on codes that cannot be billed separately without an E/M code. CPT defines 99354 as “prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour.” For example, an established patient is seen with a level-five office visit—typically 40 minutes long—but an extensive work-up is performed due to multiple diagnoses which requires the physician spend an extra 20 minutes with the patient. In this case, it is appropriate to code the claim as 99215 and 99354.
The non–face-to-face prolonged service codes without direct patient contact are 99358 and 99359. CPT defines codes 99358 and 99359 as used when “a physician provides prolonged service not involving direct (face-to-face) care that is beyond the usual non–face-to-face component of physician service time.” These codes are to be reported in relation to other E/M services at any level, but may be reported for a different date of service than that of the primary E/M service that they are related to. For instance, if a physician spends an hour extensively reviewing a new patient’s medical records prior to their office visit, the time spent would be documented and included in the patient’s medical record during their scheduled visit. CPT codes 992XX and 99358 would be billed. For each additional 30 minutes over the first initial hour of the prolonged service, CPT code +99359 should be used. Note that 99359 is an add-on code and cannot be billed separately without 99358.
Keep in mind that Medicare will typically not reimburse for prolonged services—both face to face and non–face to face—but some private carriers do; therefore, verify insurance policies regarding these services.
For more information on documenting for the use of time, download a copy of the ACR’s Rheumatology Coding Manual at www.rheumatolgy.org/publications, review the E/M services guidelines in the current CPT manual, or read Medicare’s “Documentation Guidelines for E/M Services” at www.cms.gov.
Time plays an important role in the selection of the most appropriate code for services beyond the normal scope of work, and proper documentation can be financially rewarding. If you have any questions, contact Melesia Tillman CPC-I, CRCH, CHA, at [email protected] or (404) 633-3777, ext. 820.
