Prior to 2021, the time associated with CPT codes 99202-99215 was based specifically on the typical face-to-face time the physician/qualified health care professional (QHP) spent on the day of the encounter. After 2021, providers may select the level of office and outpatient evaluation and management (E&M) services based on either time or medical decision-making. In this article, we provided guidance on selecting E&M based on time and discussed activities where time may be counted; and may not be counted.

The time-related rule requiring that 50 percent or more of the visit be spent on counseling and/or coordination of care to report the service based on time is no longer applicable. The new definition is based on ‘total’ time (face-to-face and non-face-to-face) spent by a physician/qualified health care professional (QHP) on the day of the encounter. ‘Total’ time includes both face-to-face and non-face-to-face activities performed by the physician or qualified healthcare professional on the date of the encounter. It does not, however, include time in activities that are normally performed by clinical staff. This is a significant departure from E&M guidelines which only allowed for face-to-face time to be counted.

Times-Based CPT Codes

The intervals of total time corresponding to CPT codes 99202-99215 are defined as: 

• For new patient: CPT 99202 (15-29 mins); CPT 99203 (30-44 mins); CPT 99204 (45-59 mins); CPT 99205 (60-74 mins)
• For established patient: CPT 99211 (N/A); CPT 99212 (10-19 mins); CPT 99213 (20-29 mins); CPT 99214 (30-39 mins); CPT 99215 (40-54 mins)

Activities Contribute Towards Time

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing the separately obtained history
• Performing a medical appropriate examination and/or evaluation
• Ordering medications, tests, and procedures
• Counseling and educating the patient/family/caregiver
• Referring and communicating with other health care professionals (when not reported
• separately)
• Documenting clinical information in the electronic or other health records
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

Activities Don’t Contribute Towards Time

• Time spent on a Primary Care Exception service
• Time spent on a previous or subsequent day
• Activities performed by clinical staff (i.e., RNs, MAs)
• When the E&M is warranted and separately identifiable, the time spent on separately reportable services (such as procedures, diagnostic tests, and professional interpretation) cannot be combined with the E&M time.
• Overlapping time spent between an NPP and Physician for the purpose of split-shared billing
• Time spent on travel
• Time spent on teaching that is general

Activities May Contribute Towards Time 

Both face-to-face and non-face-to-face time personally spent by the Physician/QHCP or Teaching Physician on qualifying activities on the day of the encounter may contribute towards time. Time the Teaching Physician is present when the resident is performing qualifying activities on the DOS. Qualifying activities include: 

• Preparing to see the patient (e.g., review of tests)
• Obtaining/reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling/education of the patient/family
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not separately reported)
• Documenting clinical information in the electronic or other health records
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

Split/Shared Visits 

In circumstances where the physician and another qualified healthcare professional each perform face-to-face and non-face-to-face work for a visit, the time spent by each is summed for the total time. For example, if a physician spends five minutes of time with an established patient and the NP/PA spends 25 minutes on the date of the encounter, the total time of the visit would be 30 minutes (5 + 25); therefore, CPT code 99214 (30 to 39 minutes) would be selected per the new time intervals. Although the concept of shared or split services has been around for a long time, it was previously defined by Medicare in its claims processing manual. Medicare has not changed its rules related to incidents to billing or split/shared visits. Review all commercial payer contracts regarding bills for nurse practitioners and physician assistants before making any changes based on CPT rules. 

MedicalBillersandCoders (MBC) is a leading medical billing company providing complete medical billing and coding services. We referred AMA document on ‘Code and Guideline Changes’ to discuss selecting E&M based on time, you can refer to the following link for a detailed understanding. For any assistance in medical billing and coding for your practice, contact us at [email protected] / 888-357-3226

Reference: American Medical Association: Code and Guideline Changes

CPT Code: Copyright 2022 American Medical Association

The post Selecting E&M Based on Time appeared first on Leading Medical Billing Services.