Understanding Time Based Evaluation and Management (E/M) Billing Overhaul
In an effort to reduce the burden and improve payment for cognitive care, the American Medical Association along with the Centers for Medicare and Medicaid Services (CMS) have implemented key changes to office and outpatient evaluation and management (E/M) services (all other E/M services will remain unchanged) starting on January 1, 2021. Now, providers have to select E/M services based on the level of medical decision-making as defined for each service or the total time spent on the date of the encounter. In this article, we discussed this time-based evaluation and management (E/M) billing overhaul, focussing on time calculation.
- The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 was done to assist in selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215). Different categories of services use time differently. It is important to review the instructions for each category.
- 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, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-face with the patient.
- Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.
- When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.
A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (i.e., when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted). When prolonged time occurs, the appropriate prolonged services code may be reported. The appropriate time should be documented in the medical record when it is used as the basis for code selection.
Total time on the date of the encounter (office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
Activities Contributing towards Time
Physician/other qualified health care professional time includes the following activities, when performed:
- preparing to see the patient (e.g., review of tests) § obtaining and/or reviewing separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- 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 record
- independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
- care coordination (not separately reported)
Do not count time spent on the following:
- the performance of other services that are reported separately
- teaching that is general and not limited to discussion that is required for the management of a specific patient
Legion Healthcare Solutions is a reliable medical billing company providing complete medical billing and coding services. We referred American Medical Association’s (AMA) document to discuss this time-based evaluation and management (E/M) billing overhaul, you can check the reference link for a detailed understanding. Due to the time crunch, it’s challenging for healthcare providers to keep track of medical billing and coding guidelines. Submitting claims as per revised billing and coding guidelines can be done by collaborating with medical billing partners like Legion Healthcare Solutions. We can assist you in submitting accurate claims as per payer-wise, state-wise, and medical specialty-wise billing and coding guidelines. To know more about billing and coding services, contact us at 727-475-1834 or email us at email@example.com
Reference: Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes