Revisiting E/M coding based on time

July 28th, 2017 / By Rebecca Caux-Harry

Recently, I received a question from a reader concerned about a provider coding counseling/coordination of care for the majority of the higher level new patient visits as well as the follow-up visit. In general, the reader asked if there was a compliance concern due to the frequency of this type of documentation and that the NPP (nature of presenting problem) and E/M elements did not add up to the level of care supported by the time. In describing the situation, she noted that the total time documented for all patients seen on a given day does not exceed the provider’s schedule.

So, let’s look at this from a couple of angles. First, let’s consider CPT:

“When counseling and/or coordination of care dominates (more than 50 percent) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.” 

To meet CPT direction, we must see three things: Total time spent, counseling/coordination of care dominating the visit, and description of the counseling/coordination of care provided.  When auditing these types of records, the total E/M points don’t need to add up to a code equal to that attained by coding based on time. In fact, I wouldn’t expect them to. Additionally, within the CPT manual, there is no caveat about NPP with regard to coding based on time.   

Now, the argument against this direction from CPT is that coding for counseling and coordination of care isn’t expected to be the norm. I’ve seen this comment on most MAC (Medicare Administrative Contractor) websites. My counter is that I would expect it to be the norm for new patient visits with an Oncologist, and possibly/probably a Pulmonologist. Chronic condition management is complex and patients will have a lot of questions. The second visit might very well be the same, as it could include reviewing all of the studies, education, and plan of care again for a confused or frightened patient. As the patient gains familiarity with their condition, I would expect that the need for counseling would be reduced, and therefore coding for subsequent visits would revert to E/M elements.   

One additional note: CMS has said that the medical necessity of the presenting problem should be the overarching criterion for selecting a level of care. I believe this direction is to be used for established patients where there is a complete history and exam documented, but MDM (Medical Decision Making) isn’t all that high. To me, this would apply when coding based on E/M elements and not when coding on time. Again, this is my opinion, but I believe the recent statement by CMS about possibly updating the E&M documentation guidelines supports my belief. The proposed rule can be found here with E&M discussion starting on page 373.

As you can see, there is a great deal of nuance when coding E/M visits. Being a coder, I certainly wouldn’t question the provider’s opinion about the NPP or MDM. I don’t have the education to do that. What coders can do, however, is give guidance to the provider about proper documentation and code selection. Based on the reader’s question and without reviewing documentation, I don’t see a compliance concern here.

Find more time-based blogs from me here.

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.