When the office-based E/M coding guidelines changed in 2021, coders faced a huge learning curve. It involved transitioning from selecting the right code based on history, exam and medical decision making (MDM) to choosing the most appropriate code based on either time spent or MDM only. And while coders have weathered the change by now, the reality is that many practices are undercoding because they don’t understand which activities they can count toward time-based coding and which they can’t.
To maximize the amount you can collect for E/M services, check out the following tips about what you can and can’t include in your time-based coding tally.
Time Counted Toward the E/M Service Includes:
- Preparing to see the patient (for instance, reviewing test results and previous records)
- Obtaining and/or reviewing a separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient or their family/caregivers
- 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
Time Counted Toward the E/M Service Should Not Include:
- The performance of other services that are reported separately (such as blood draws or vaccine administrations)
- Travel
- Teaching that is general and not limited to a discussion that is required for the management of a specific patient
- Clinical staff time
Time-Based Coding Best Practices
Remember that the total time on the date of the encounter spent caring for the patient should be documented in the medical record when it’s used as the basis for code selection. The provider should not only say how much total time was spent, but also what they did during that time period. This can help protect your practice if an auditor ever questions the amount of time you spent on a patient’s care.
For instance, suppose you saw a patient with severe allergies to multiple medications who also has diabetes and heart disease and presents with throat pain. The provider diagnoses her with strep throat and the documentation states, “I spent 45 minutes on patient care.” The provider then reports high-level E/M code 99215, which corresponds to 45 minutes. Auditors would likely question why a strep throat diagnosis required such a high-paying code. Therefore, justifying the reasons for the time spent will be important.
A statement that might be more fitting may say something like, “Today I met with Mrs. Smith, who presents with throat pain. Her daughter also mentioned that Mrs. Smith has not been managing her diabetes properly and only uses her insulin sporadically. I spent 10 minutes examining Mrs. Smith and 5 minutes interpreting her throat swab results, which revealed a strep throat diagnosis. I also spent 20 minutes advising Mrs. Smith and her daughter about diabetes management best practices and answering their questions about wound care, exercise and diet. I spent another 10 minutes conferring with Mrs. Smith’s allergist about which medications would be safe for her to take in light of her antibiotic allergies, and then sent a prescription to her pharmacy.” This still totals 45 minutes, but shows reviewers why so much time was needed.
Seeking more tips that will help you stop undercoding your E/M claims? Let expert Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CPMS, CMRS, CMCS help! During her 60-minute training event, E/M Services: Stop Undercoding, Get Paid More of What You’re Due, she’ll walk you through the key strategies you need to collect what you’re entitled to. Sign up today!
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