Questions about billing by time

[SpongeBob DoctorPants]

My understanding is that billing 99215 requires at least 40 minutes face-to-face time with the patient, 99214 requires at least 25 minutes, etc. But is there any requirement to document the starting and ending times for the encounter?

For example, let's say your patient checked in at 9:00, got their vital signs completed by your MA, entered your office at 9:05, and you ended up seeing the patient face-to-face until 9:42.

Would you document somewhere in your note that the start time was 9:05, end time was 9:42, and total face-to-face time was 37 minutes? Or can you just say the total face-to-face time was 37 minutes? Or simpler yet, round down to the nearest minimum time required for billing, and say it was 25 minutes?

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[WisNeuro]

May vary depending on your billing/coding people. I'm part of the MH clinical council at my hospital and we just had a meeting on this last week. Our guidance was that they did not need to note start and stop times, but they also needed to do less copy and pasting from week to week. We were getting kickbacks from payors because some providers had literally the same thing copied and pasted for like 12 straight visits. So, as long as you documented the actual face to face time, and didn't just say 40 minutes for everybody, that would work for our system.

 

[hamstergang]

My understanding is that billing 99215 requires at least 40 minutes face-to-face time with the patient, 99214 requires at least 25 minutes, etc.

Listing the amount of time is sufficient.

As a note, 99213 is listed as 15 minutes, 99214 as 25 minutes, and 99215 as 40 minutes, as TYPICAL times. To bill under any code requires you to see the patient for an amount of time closer to the code you pick than another code. That is, you can bill 99214 for visits lasting 21-32 minutes. For 20 minutes and less 99213 is closer and for 33 minutes and above 99215 is closer.

 

[TexasPhysician]

Coding can be time based or complexity based. If complexity based, time does not matter, but your documentation must reflect the level of services. Coding by time requires documentation of time, 50% involved in counseling/coordination, etc. if time based, you can’t use therapy add on codes.

 

[SpongeBob DoctorPants]

Listing the amount of time is sufficient.

As a note, 99213 is listed as 15 minutes, 99214 as 25 minutes, and 99215 as 40 minutes, as TYPICAL times. To bill under any code requires you to see the patient for an amount of time closer to the code you pick than another code. That is, you can bill 99214 for visits lasting 21-32 minutes. For 20 minutes and less 99213 is closer and for 33 minutes and above 99215 is closer.

Thanks for the info... if this is correct, then I have probably been undercoding quite a bit. The way our EMR is set up, they have a guide that shows up next to the billing by time option, and it clearly states that 99213 is greater than or equal to 15 minutes, 99214 is greater than or equal to 25 minutes, and 99215 is greater than or equal to 40 minutes. (They also have similar guides for using new patient codes, such as 99205 being greater than or equal to 60 minutes.) I'll have to look into this more. I suppose that whoever set up our EMR could have been wrong.

 

[SpongeBob DoctorPants]

If billing by time you need to spend at least 50% of the time in counseling and coordination of care. Also the level of service has to be appropriate so 99215 really indicates you are doing with either life threatening conditions or high complexity eg if a pt needs admission for SI or HI that would qualify. Starting a pt on an MAOI or clozapine would qualify. Just seeing a routine follow up for 40mins would not because it would not be deemed medically necessary

I appreciate your comments. I might argue, though, that one does not necessarily need to be admitting to the hospital or using complicated medications to qualify for 99215. For example, I have had some encounters in which commonly used medications are being prescribed, and there is no acute safety concern, but the encounter is complicated for other reasons, such as severe parent-child conflict, multiple problems being addressed, lengthy discussions about medication options and side effects or lab requirements, etc. Perhaps this kind of discussion would also fall under "high complexity". I usually keep my visits under 30 minutes anyway, but sometimes there are issues that come up, and out of necessity I may need to spend more time with the patient. It would be extremely rare for me to see someone for 40 minutes if everything was going well. For what it's worth, in 2018 I billed 99215 in about 4% of my clinic visits; I believe this is about right for the average psychiatrist.

Regarding the counseling and coordination of care being at least 50% of the visit... I'll be honest and say I haven't actually calculated the amount of time I spend counseling and/or coordinating care for the patient, but it very likely does take up more than 50% of my encounters. Typically, getting an update on the patient's symptoms doesn't take long, and most of the encounter is spent discussing ways in which we can make the patient's problems better.

 

[splik]

I appreciate your comments. I might argue, though, that one does not necessarily need to be admitting to the hospital or using complicated medications to qualify for 99215. For example, I have had some encounters in which commonly used medications are being prescribed, and there is no acute safety concern, but the encounter is complicated for other reasons, such as severe parent-child conflict, multiple problems being addressed, lengthy discussions about medication options and side effects or lab requirements, etc. Perhaps this kind of discussion would also fall under "high complexity". I usually keep my visits under 30 minutes anyway, but sometimes there are issues that come up, and out of necessity I may need to spend more time with the patient. It would be extremely rare for me to see someone for 40 minutes if everything was going well. For what it's worth, in 2018 I billed 99215 in about 4% of my clinic visits; I believe this is about right for the average psychiatrist.

Regarding the counseling and coordination of care being at least 50% of the visit... I'll be honest and say I haven't actually calculated the amount of time I spend counseling and/or coordinating care for the patient, but it very likely does take up more than 50% of my encounters. Typically, getting an update on the patient's symptoms doesn't take long, and most of the encounter is spent discussing ways in which we can make the patient's problems better.

I would agree those would qualify. I also gave examples of starting particular meds. I think the examples you gave for child would qualify. similarly, I use 99215 for explaining to patient and family a new diagnosis of dementia. 4% of visits sounds about right too. insurance companies audit the number of 99215s so if used too frequently you will be audited and it will be denied.

 

[Sushirolls]

I had used 99215+99354 in the past for doing patient ECT consults that came from colleagues in the same medical group. Naturally, those were all documented with time (90 minutes or more) and had a lengthy paragraph explaining the counseling/coordination of care.

 

[Armadillos]

For billing purposes are there rules of what actually counts as “coordination of care”?

 

[SpongeBob DoctorPants]

For billing purposes are there rules of what actually counts as “coordination of care”?

What constitutes "counseling and coordination of care"?

Counseling, as defined by CPT, is a discussion with a patient and/or family concerning one or more of the following areas:

• Diagnostic results, impressions, and/or recommended diagnostic studies
• Prognosis
• Risks and benefits of management (treatment) options
• Instructions for management (treatment) and/or follow-up
• Importance of compliance with chosen management (treatment) options
• Risk factor reduction
• Patient and family education

Source: Frequently Asked Questions | psychiatry.org