Fun Coffee with CCO #22

[Lori]

Good Morning Coders!
What are you coding today?

Selecting E/M Codes by Total Time​

Total time may be used alone to select the appropriate code level for office visit E/M services (99202-99205, 99212-99215). A key change in the new guidelines is the updated definition of time. Time may be used to select the level of service regardless of whether counseling dominated the encounter. The revised definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes activities such as:

• Preparing to see the patient (e.g., review of tests);
• Obtaining and/or reviewing separately obtained history;
• Ordering medications, tests or procedures;
• Documenting clinical information in the electronic health record (EHR) or other records; and
• Communicating with the patient, family, and/or caregiver(s).

Time spent in activities normally performed by clinical staff (e.g., time spent by nursing or other clinical staff collecting a patient’s history) should not be counted toward total time. Furthermore, time spent on a date other than the date of service should not be counted toward total time. For example, completing documentation on the day after the encounter would not be counted toward the total time when selecting the level of service for the encounter. Finally, time spent on services that are separately reportable (e.g., independent interpretation and reporting of test results, tobacco cessation counseling) should not be included in total time calculations.

Each code now has a specific time range. Physicians should ensure they document the total time spent on the date of the encounter in the patient’s medical record. Physicians should avoid documenting time ranges and instead document specific total time spent on activities on the date of the encounter

CPT Code	Time Range
99202	15-29 minutes
99203	30-44 minutes
99204	45-59 minutes
99205	60-74 minutes
99212	10-19 minutes
99213	20-29 minutes
99214	30-39 minutes
99215	40-54 minutes

Coding for Evaluation and Management Services: FAQs

Maximize payment and reduce stress by understanding how to properly document and code for evaluation and management (E/M) services.

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