CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC , a training and credentialing association for the business side of health care. Occasionally, a health care provider’s discussions with a patient about his or her medical condition(s) may consume a greater portion of the provider/patient encounter than the time devoted to performing a relevant history, exam and medical decision-making (MDM). In such cases, CPT® guidelines allow you to consider time as “the key or controlling factor to qualify for a particular level of evaluation and management (E/M) services.” When using time to determine a proper E/M service level, you must be careful to follow four conditions. Condition 1: The E/M service to be reported must have a “reference time.” The reference time provides an objective standard by which to determine whether “more than 50 percent” of the visit is spent in counseling and/or coordination of care. A reference time typically is indicated in the code descriptor with the statement, “Typically, xx minutes are spent face-to-face with the patient and/or family.” For example, reference time for established outpatient codes are: 99211 = 5 minutes 99212 = 10 minutes 99213 = 15 minutes 99214 = 25 minutes 99215 = 40 minutes CPT® states, “When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used.” For example, when reporting a time-based, established outpatient E/M lasting 19 minutes, you would report 99213. Note that not all E/M service codes include reference times. For example, CPT® states, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis…” Likewise, observation codes 99234-99236 do not have a reference time. Because these services do not include reference times, you may not report them using time as the controlling element. Condition 2: Counseling or coordination of care must dominate the encounter. Per CPT® requirements, you may report E/M services by time only if counseling and/or coordinating care dominate the physician/patient encounter. In other words, counseling and coordination of care must consume more than 50 percent of the total time devoted to the visit. Counseling and coordination of care entail a discussion with a patient and/or the patient’s caregiver(s) concerning one or more of the following: • Diagnostic results, impression, and/or recommended diagnostic studies • Prognosis • Risk and benefits of management (treatment) options • Instructions for management (treatment) and/or follow up • Importance of compliance with chosen management (treatment) options • Risk factor reduction • Patient and family education For example, if a physician spends 20 minutes of a 30-minute patient encounter answering a patient’s questions about a new diagnosis and counseling the patient on treatment options, it is appropriate to consider time as the deciding factor when assigning an E/M service level. Condition 3: For outpatient visits, time must be face-to-face. In the context of office and other outpatient visits, “time” refers specifically to time spent face-to-face with the patient, as well as “time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members.” Note, however, that in a hospital or nursing facility, time also may include floor/unit time. Condition 4: The extent of the counseling and/or coordination of care must be documented in the medical record. When a provider documents an E/M service based on the history, exam and MDM, he or she must provide detail sufficient to determine the “level” of each of these individual components. The provider does not document, for instance, “I performed a comprehensive history.” Instead, he or she details the information relevant to the history of present illness descriptors, such as location, quality, severity, the number of body systems reviewed, and so on. The same logic holds true when documenting time. It’s not enough to state how long the service lasted, or that counseling or coordination of care dominated. The documentation must detail the content of the visit to support time as the controlling factor when reporting E/M services, as well as to support overall medical necessity for the service. The Medicare Claims Processing Manual , Chapter 12 Section 30.6.1.C, explicitly states: … when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. …the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim. [emphasis added]. The 1995 and 1997 E/M Documentation Guidelines concur: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care . [emphasis added]. Providers should avoid characterizing time in broad or inexact terms. For example, coders and auditors cannot use time to determine the level of service when a provider indicates that he or she had a “lengthy discussion” with the patient. Best practice is to note the total time of the visit, the total time spent in counseling or coordination of care, and a synopsis of the discussion. The note within the medical record can be a thorough account of the activity with the patient, the recommendations and the patient’s concerns. The physician shouldn’t limit the documentation to only the time and counseling information, but should also include the information gathered from the history and examination elements, as well as MDM concerning reviewed tests, ordered tests, co-morbid conditions, etc., to further substantiate the level of service and the time spent counseling. Providers justifiably feel bogged down by documentation or coding requirements that seemingly have little to do with patient care, but in this case the documentation requirements match clinical best practice and necessity. The medical record serves many functions—as a means to assign codes for payment, as a legal document, etc.—but, primarily, it is a “snapshot” of the patient’s condition at a given moment, and a tool to communicate with other providers. Never mind what a coder or auditor sees: Would another provider (or even the same provider, referencing the record weeks or months later) be able to determine what was discussed at the visit, based on the documentation provided? A medical record lacking pertinent details about the content of a counseling session, or what coordination of care at a particular visit entailed, fails at its primary, clinical purpose.