In the realm of Evaluation and Management (E/M) coding, time can be a crucial factor in determining the appropriate service level. Specifically, when Coding Counseling And Coordination Of Care significantly outweighs other aspects of a patient encounter, it can become the deciding element. This principle applies when counseling and/or coordinating care consumes more than half of the total time spent with the patient. This guideline is relevant for non-time-controlled E/M services that have reference times designated by the American Medical Association (AMA) in the CPT® code book.
This time-based rule for coding counseling and coordination of care is applicable to a range of outpatient and inpatient services, including:
- Outpatient new and established patient visits (99201-99215)
- Outpatient consultations (99241-99245)
- Inpatient new and subsequent visits (99221-99233)
- Inpatient consultations (99251-99255)
- Observation initial visit (Outpatient) (99218-99220)
- Observation subsequent (Outpatient) (99224-99226)
- Observation admit & discharge – same calendar day (Outpatient) (99234-99236)
- Nursing Facility Care (Inpatient) (99304-99310)
It’s important to note that this rule does not extend to Emergency Department Visits (99281-99285) and preventative care visits (99381-99396), as these categories lack reference times assigned by the AMA in the CPT®. Similarly, time-based codes for critical care (99291-99292) are also excluded from this guideline for coding counseling and coordination of care.
Essential Documentation Elements for Time-Based E/M Coding
When utilizing counseling and/or coordinating care as the primary factor for determining the E/M code level, there are three critical documentation elements that must be clearly stated in the medical record. These elements are crucial for accurate coding counseling and coordination of care:
- Total Encounter Time: The total duration of the patient encounter must be documented. This includes all time spent with the patient, whether face-to-face or on the floor in inpatient settings.
- Dominant Counseling/Coordination Time: The documentation must explicitly state the time spent on counseling and/or coordinating care. This time must be greater than 50 percent of the total encounter time to qualify for time-based coding.
- Content of Counseling and Coordination: Detailed topics discussed during counseling and specific areas of care coordinated must be documented. This can be presented as a bulleted list for clarity and comprehensiveness.
For instance, consider subsequent outpatient visits with AMA reference times:
- 99212: 10 minutes
- 99213: 15 minutes
- 99214: 25 minutes
- 99215: 40 minutes
Imagine a scenario where a physician spends 30 minutes with a patient post-biopsy, discussing malignant results and treatment options. If 20 minutes are dedicated to face-to-face counseling about surgical options, success expectations, post-surgical care, and chemotherapy/radiation, and all patient questions are addressed, the documentation might read: “Total encounter time: 30 minutes. 20 minutes spent counseling patient on biopsy results and options. Topics discussed: Biopsy results, Surgical options, Success expectations, Post-surgical expectations, Post-surgical treatment options. Patient questions answered.”
In this case, despite potentially limited documentation in history, exam, and Medical Decision Making (MDM), the encounter can be coded as 99214 because the coding counseling and coordination of care criteria are met, with counseling exceeding 50% of the visit time.
For inpatient status (hospital or nursing home), total time includes floor time, encompassing counseling with family and care coordination. AMA CPT® reference times for subsequent hospital visits are:
- 99231: 15 minutes
- 99232: 25 minutes
- 99233: 35 minutes
Crucially, remember that patients in observation are classified as outpatients. Therefore, for observation services, only face-to-face time with the patient is counted; floor time is not applicable when coding counseling and coordination of care for these patients.
By accurately documenting these three key elements – total time, dominant counseling/coordination time, and content of counseling and coordination – healthcare providers can confidently utilize time as a controlling factor in E/M coding when counseling and care coordination are paramount to the patient encounter. This ensures appropriate reimbursement and reflects the true nature of patient care when coding counseling and coordination of care.
