Coding & Reimbursement

Coding E/M Visits Using Time

By Suzanne L. Corcoran, COE

Under most circumstances, E/M coding depends on the extent of the medical history, exam and medical decision-making. Sometimes, however, using time as the sole defining element is a better approach.

Q. How is time used to determine an E/M code?

Instead of the elements I mentioned above, time may be used to select an E/M code when the following criteria are met:

• Only face-to-face time by the physician counts. For coding purposes, that is defined as time that the physician spends face-to-face with the patient and/or family.
• More than half the time is spent counseling the patient and/or family. CPT says, "When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter … then time may be considered the key or controlling factor to qualify for a particular level of E/M services. …The extent of counseling and/or coordination of care must be documented in the medical record."

Q. How is the time documented?

A precise entry in the chart note must describe the duration of the exam, typically at the conclusion of the medical record. It may contain start and stop times for physician face-to-face time with the patient, particularly when the physician's involvement is interrupted (e.g., time for dilation in the drop area). It is not appropriate to rely on blocks of time in the practice's appointment schedule to determine the length of the exam. Practices that commonly use time as the key element in choosing a visit code can develop a specific form as an aid for the doctor (Figure 1).

Figure 1. Sample office form for coding by time.

Q. How much time is required?

It varies according to the type of visit, being greater for a new patient than for an established patient, and greater still for consultations (Figure 2).

Figure 2. E/M coding requires specific time periods for particular codes.

Q. Does testing count toward face-to-face time?

Unless the test is personally administered by the physician, such as quantitative sensorimotor exam (92060) or gonioscopy (92020), most testing does not count toward face-to-face time with the patient. This is because the test is delegated to a medical assistant or technician.

Q. How does the physician account for time beyond those shown above?

Prolonged services (CPT 99354-99357) are used when a physician provides an exam or consultation involving direct face-to-face patient contact that is beyond the usual service. Prolonged service begins once the face-to-face criteria for the highest applicable E/M service has been satisfied.

Q. What types of visits might use time as the key element in selecting an E/M code?

Examinations of infants and children, patients with low vision, and exams requiring a translator are examples of time-consuming office visits. Neuro-ophthalmologists, as a group, tend to spend a great deal of time with patients. Likewise, pediatric ophthalmologists frequently engage in extended discussions with family members and caregivers. Patients with rare syndromes or those with very complex medical histories can be challenging and necessitate a lengthy exam.

The field of low vision rehabilitation (LVR) is characteristically very time consuming, particularly for the initial evaluation, which must document the specific visual impairment, the functional deficits imposed by this impairment and the patient's ability to benefit from LVR.

Q. Is time a factor for eye codes?

No. Time is not relevant in choosing an eye code (920xx). OM