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time based coding question

Angela Posted Fri 15th of July, 2011 04:13:25 AM

I know that cms and cpt state that when choosing to code based on time that the counseling must exceed 50% of the visit.
Is it defined anywhere that it must exceed 50% of the total visit time, or exceed 50% of the time associated with the code selected, I have read both as suggestions by others, but woud like CPT or CMS statement on the matter.
Examples would be typical time for a 99214 is 25 minutes.
documentation states 15 minutes of a 30 minute visit spent...etc.
How do I tell my physician that had he spent 5 minutes less with the patient then he would qualify for a 99214, otherwise he is now only going to get a 99212 (based on key elements) since 15 is not MORE than half of 30???? Especially when the code selection he is interested in acheiving is a 99214 and 15 minutes is MORE THAN half of 25??
Any supporting documentation in this matter would be appreciated.

SuperCoder Answered Fri 15th of July, 2011 17:05:39 PM

If documentation states "15 minutes of a 30 minute visit spent", you should not code it based on Time.
You should protect your pay by following this guideline:
If documentation doesn't specify that the encounter has met the "more than 50 percent counseling requirement"
- DO NOT use Time as the controlling factor to select the level of E/M service.
- DO Code based on History, Exam and MDM.

On the other hand, "in selecting time, the physician must have spent a time closest to the code selected," states CPT Assistant Aug.2004.
CPT Assistant indicates to use when couseling/coordination of care dominates face-to-face office time totalling this many minutes: []
99212: 10-12.5
99213: 12.6-20.5
99214: 20.6-32.5
99215: 32.6 or more
So, while calculating total time, you can follow above threshold time break-ups, but in the context of more than 50% of the total visit time, this rule has to be strictly followed.

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