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billing E/M codes

Aida Posted Thu 11th of June, 2015 15:42:23 PM

when billing 99212 - 99215 does the exam portion have to be included.
or can the amount of time spent with the patient be considered to bill the level 99212 - 99215 without doing the exam.

If the exam portion does not need to be included does the time have to appear on the note.

According to the cms website, the exam portion has to be included with a minimum time limit.

Please advise.

SuperCoder Answered Fri 12th of June, 2015 03:06:59 AM

EM codes can be billed based on either the key components (H, E, M) or time spent in coordination and care. 99212-99215 are established codes so having data for 2 key comp. are enough. Having documentation for exam is not mandatory. If you have history and MDM points you can still build an est. code.

To do time-based coding, you must have the total F2F time mentioned in the records as well as documentation on how much time has been spent in counseling & coordination of care (time for CC). If both times are mentioned in terms of minutes, you can find out if the time for CC is more than 50% of the total F2F time and code based on time. If time for CC is not mentioned but it's documented that the physician has spent more than 50% of the total F2F time in counseling & coordination of care, that's OK too. You can use that statement and bill a time-based code. Again you don't need key components when you are coding based on time.

Aida Posted Fri 12th of June, 2015 09:33:05 AM

okay, what do you mean by F2F... what if the provider just enter the time on the EMR to be able to get the billing code and not on the note. Can she just enter the minutes only?

SuperCoder Answered Mon 15th of June, 2015 03:16:35 AM

F2F is "face to face" visit. Typically the CPT official code descs. contain the time in terms of F2F. But just a documentation of that time is not enough. There must be documentation of how much time has been spent in counseling & coordination of care. If that time is not more than 50% of the total time spent between the provider and the patient, you cannot bill a time-based code.

The provider can either write the total time spent with the patient in the EMR or in the hand written notes, however in the absence of the indication of the counseling & coordination of care time, either in percentage or in minutes, you cannot bill time based code (even though the code desc. states nowhere the amount of time spent in counseling & coordination of care).

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