Download the full PDF version.
If you look through your Current Procedural Terminology (CPT®) book, you will notice that many of the evaluation and management (E/M) code descriptors include typical times. These typical times are averages of how long it takes a physician to complete all components of a visit at that level. As is true with averages, some times are going to be higher and some will be lower, depending on the actual clinical circumstances. Therefore, in most cases, time is only a “contributory factor” in determining which level of evaluation and management (E/M) to report for a visit. Usually, a level of E/M service is determined by the “key components” of history, examination, and medical decision making. However, if you end up spending greater than fifty percent of the total visit counseling/coordinating care, you can use time as the key factor in determining the level of E/M service that you report. Typical times are listed below for new and established office or other outpatient E/M services:
|New Patient Visit||Typical Time (minutes)|| Established Patient Visit||Typical Time (minutes)|
Here’s an example:
You see a 20‐month old child with an injured leg and complete two out of the three key components (expanded problem focused history, expanded problem focused exam, or medical decision making of low complexity) necessary to code a 99213. Upon review of the chart, you notice that the child is due for a refill on his asthma medication. You ask the mom how it has been going with the current medications and the mom starts talking about recent issues with getting the child to cooperate taking his medications. The physician spends a great deal of time counseling the mom on ways to administer the medications and how to be sure the child is getting enough. The physician also discusses the important of taking peak flow meter ratings.
If you look in your CPT book, you will note that 99213 lists a typical time of 15 minutes, while a 99214 has a typical time of 25 minutes.
In order to determine whether you can code for time as the key factor, you need to answer the following questions:
- How much time did I spend either counseling or coordinating care for the patient?
- How much time did I spend in total for the whole visit (including time spent providing key components and time spent counseling and/or coordinating care)?
- What percentage of B is A?
If the answer to C is equal to or less than fifty percent, then the key components should be used to determine the level of code to report. If the answer to C is greater than fifty percent, then you can use time as the key factor in determining which level of service to report; the level of key components is no longer a factor for determining the level of code to report. From our example above:NOTE: In every case, it is imperative that you document the extent of the counseling/coordination of care in the medical record.QUIZQ.
If the answer to B is 30 minutes and the answer to A is 16 minutes, then the answer to C is 53% and you could then report a 99214 (typical time for 99214 listed in CPT is 25 minutes).
To drive home the point, here are some variations with different results:
If the answer to B is 40 minutes and the answer to A is 22 minutes, then the answer to C would be 55% and you could then report a 99215 (typical time for 99215 listed in CPT is 40 minutes).
If the answer to B is 42 minutes and the answer to A is 19 minutes, then the answer to C would be 45% and you would then report a level of service based on key components (in our example above, you would report 99213).
A 7‐year‐old child comes in at the end of the day with his mother and father for follow up of response to methylphenidate started 3 weeks ago for ADHD. Vital signs, including blood pressure, height and weight are obtained. You review the results of pre‐ and post‐
Connor Scale questionnaires from the parents and teachers. You question the child and family regarding appetite, tics, and other potential side effects. Everything seems to be going well and no further adjustment in medication is made. The child’s mother, who was not present at the last visit, has multiple questions and concerns regarding such therapy, which you address. What would normally have been a fifteen‐minute visit has lasted 40 minutes, with 22 minutes of the total visit being devoted to counseling the patient and his parents. How would you appropriately bill for this encounter?
A.This is not the correct answer.
99213 Office/outpatient visit, established patient, which requires 2 of 3 key components: an expanded problem focused history, an expanded problem focused examination, or medical decision‐making of low complexity. Physicians typically spend 15 minutes face‐to‐face with the patient and/or family.
A typical 15‐minute encounter for this type of visit would have likely been coded as a 99213 visit (office/outpatient visit, established patient) which requires 2 of 3 key components:
- an expanded problem focused history,
- expanded problem focused examination, or
- medical decision making of low complexity
CPT suggests this typically takes about 15 minutes, and would have, if the mother had been there during the previous visit. As a result of the additional time spent counseling the family, which was the majority of the total visit time (22 minutes is 55% of 40 minutes), you can bill using time as the key factor.When Time Spent Falls Between Two Typical Times
99215 Office/outpatient visit, established patient, which requires 2 of 3 key components: a comprehensive history, a comprehensive examination, or medical decision‐making of high complexity. Physicians typically spend 40 minutes face‐to‐face with the patient and/or family.
Remember that times listed in CPT for E/M services are the typical times it takes a physician to complete all components of a visit of that level. Some times are going to be higher and some will be lower, depending on the actual clinical circumstances. Therefore, in most cases, time is only a “contributing factor” in determining which level of E/M code to report. Usually the “key components” of history, examination, and medical decision making should be used. However, if you spend greater fifty percent of the visit counseling and/or coordination care, you can use time as the key factor. In this case because 40 minutes was spent, you report the 99215 instead of the 99213. Be certain to document the encounter’s duration in the chart for that visit including total time spent in counseling/coordination of care.
If the total time of a visit falls in between two reference codes (eg, a 20 minute visit, which falls just halfway between a 99213 [15 minutes] and a 99214 [25 minutes]), you need to determine if the time spent is closer to the lesser time [eg, 15 minutes] or the longer time [eg, 25 minutes]. If the time spent is closer to the lower typical time report the code with the lower time. If the time spent is closer to the higher typical time, report the code with the higher typical time.
Example: Physician spends 20 minutes with an established patient and parent. 15 minutes are spent in counseling/coordination of care. Since 20 minutes falls directly in between a 99213 [15 mins] and 99214 [20 mins], what do you report?
- 99213 – When the time spent is exactly the mid-point between 2 codes, you round down.
Example: Physician spends 40 minutes with a new patient. Of that time over 30 minutes is spent in counseling/coordination of care. Since 40 minutes falls in between a 99203 [30 mins] and a 99204 [45 mins], what do you report?
- 99204 – Because the typical time mid-point was passed [ie, 38 mins] you can round-up to the higher code.
Example: Physician spends 30 minutes with an established patient and parent. The entire visit is spent in counseling/coordination of care. Since 30 minutes falls in between a 99214 [25 mins] and 99215 [40 mins], what do you report?
- 99214 – Even though you went over the typical time required for code 99214, you did not pass the mid-point therefore you round down.
The above guidelines for reporting when time spent falls between two typical times is a CPT guideline. Some Medicaid payers may differ. Caveat:
If you perform counseling/coordination of care for greater than 50% of a visit yet the total visit time does not meet the typical time requirement of even the lowest level code, you cannot use time as your key factor.Prolonged Services:
As a result of lengthy counseling/coordination of care encounters, time spent can go beyond even the highest typical time in the code set. When this happens, you can look to adding prolonged services. However, when using time as your key factor, prolonged services can only begin when you have reached a minimum of 30 minutes beyond the typical time listed in the highest code in the code set (eg, 99205, 99215).
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)+99355
Each additional 30 minutes (Use in conjunction with 99354) Example:
Physician spends 80 minutes with a new patient. Of that time over 60 minutes is spent in counseling/coordination of care. What do you report?
99205 (60 minutes) Can you add-on prolonged services? No. Because the time spent was only 20 minutes above the typical time listed in the highest code (99205 = 60 minutes). You need a minimum of 90 minutes to add on prolonged services.Example:
Physician spends 80 minutes with an established patient. Of that time over 60 minutes is spent in counseling/coordination of care. What do you report?
99215 (40 minutes)
Can you add-on prolonged services? Yes. Because the time spent was greater than 30 minutes beyond the typical time listed in the highest code (99215 = 40 minutes). You would then also report 99354 in addition to the 99215 (no modifier is needed).
Prolonged Clinical Staff Services with Physician or Other Qualified Health Care Professional Supervision
Codes 99415, 99416 are used when a prolonged E/M service is provided in the office or outpatient setting that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code description.
+ 99415 Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour
+ 99416 each additional 30 minutes
Refer to the prolonged services resource for more details.
Patient not Present
Often times in pediatrics, a parent or other legal guardian will present to the office to discuss a condition with the pediatrician without the patient present. Reasons vary for the appropriateness of this type of encounter, but may include a new diagnosis of a chronic medical condition or a diagnosis of a mental or behavioral issue where it might not be appropriate for the child to be present. Because the patient is not present most often these encounters will be based solely on time, given that counseling and coordination of care will dominate.
The AAP is often asked
- Can we bill for these services when the patient is not present?
- If we can, what codes (CPT® and ICD) can we report?
The answer to #1 is yes based on CPT. The reason is, CPT states that you either code an E/M service based on the selection of your key components (history, exam, medical decision making) or based on time. In order to report the E/M service based on time more than 50% of the total face-to-face time must be spent in counseling and/or coordination of care. CPT also goes on to say “For coding purposes, face-to-face time for these services is defined as only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.”
The answer to #2 is that you will report an appropriate office or other outpatient encounter (99201-99215) depending on if the patient is new or established to your practice. The controlling factor in determining the level will typically be based on time spent with the parent or legal guardian. Note it would not be appropriate to report a consultation code as parents or legal guardians cannot initiate a consultation. Your ICD codes will relate to the conditions or issues being addressed during the encounter. If a patient’s new diagnosis of diabetes mellitus is the reason the mother presents to your office, report the appropriate diabetes mellitus code as the primary reason for the encounter.
It is important to note that some payers, including Medicare and some state Medicaid plans, require that the patient be present. Always check with your payers as their policy may differ from CPT guidelines.
Be certain to document the encounter’s duration in the chart for that visit including time spent in counseling/coordination of care.