Is Time-Based Billing and Documentation Something We Should Think About?

Friday, May 24, 2019 | Nicole Knight

Impending coding and documentation changes by CMS and the American Medical Association (AMA) have been sparking conversations lately. Physicians, Administrators, Coders, etc. are asking us how these changes could impact cardiovascular services and how to prepare for them. 

According to a recent announcement, the AMA is planning to simplify Evaluation and Management (E/M) service codes and documentation requirements in the 2021 CPT® book. The AMA has published impending changes including deleting CPT® code 99201, removing the requirement to document the amount of history and number of examination elements, and changing the basis for E/M code selection to focus on the level of medical decision making performed or the total time spent performing the service on the day of the encounter. This follows the initiatives by CMS to revamp E/M services that started in 2018 and continue to evolve.

All of the buzz has me thinking about how important documentation for time-based billing is and how Cardiovascular providers are often reluctant to use time as a driving factor.

Coding based on time is expanding beyond E/M service codes with virtual, remote patient monitoring, prolonged care, etc. It’s time to evaluate your time-based coding and documentation effectiveness, evaluate training needs, and plan for future opportunities.

Here are a few things to start looking at: 

1. What is Time? – The AMA describes three kinds of time:
   1. Face-to-Face: direct face-to-face time between the billing provider and the patient or family generally only applies to office or other outpatient visits.
   2. Floor/unit: Billing provider is physically present on the patient’s floor or unit delivering services to the patient. It includes both time spent with the patient and/or directly related to the patient. Occurs generally in an inpatient setting.
   3. Non-face-to-face: occurs when performing work related to the patient before and after the face-to-face time or floor/unit time with that patient. It includes tasks such as review of medical records, communication with other healthcare providers, etc.
2. Review the E/M documentation guidelines based on time. CPT® details the average amount of time physicians spend on various levels of E/M services. The following are required to bill E/M services based on time as the driving factor.
   1. Documentation of exact time – clock time or total time is acceptable. Avoid use of “greater than 30 minutes”, this does not meet the exact time requirement.
   2. If a provider spends more than 50 percent of a face-to-face visit counseling or coordinating a patient’s care, the provider can code the visit on the basis of time, even if the history, exam or medical decision-making elements are lacking.
   3. The extent of counseling and/or coordination of care must be documented in the medical record. Describe the counseling or activities to coordinate care.
3. Are there patient populations and/or activities in the practice that would support billing for non-face-to-face prolonged E/M services? As an example, the complexity of Cardiovascular patients such as chronically ill heart failure patients may require extensive non-face-to face time and management. CPT® contains two codes for prolonged services that are not face-to-face: 99358 and 99359. These are for pre- and post-care services provided in either the outpatient or inpatient setting. Code 99358 is used for the first 30 minutes to an hour of service, and code 99359 is used for each additional 30 minutes on a given day.

CMS stresses codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.” CMS further stipulates, “99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff).” Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time is not continuous,” according to CPT®. Documentation should summarize the necessity and specific content of the prolonged services.

Despite warnings and disclaimers to the contrary, time is central to the E/M coding system. Though it may not always determine what code is selected for the primary E/M service, it does play an important role in selecting the appropriate code for prolonged services, for services that involve extensive counseling or coordination of care, and for time-dependent codes. A better understanding of the rules on the basis of time will help providers secure fair compensation for all the services they provide.

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