Time Documentation in the Post-Consult Era

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I don't wear a wristwatch.
I have three basic reasons why you'll never find a time piece in my possession.
The first being my dislike of all things related to jewelry.
I've been married for nearly 5 years and I still play with my wedding ring, which is my only piece of jewelry.
The second is I am surrounded by clocks at all times.
As I type this, I have a clock on the phone, computer and fax machine in my work area.
Why complicate it by putting something on my wrist? The third is more cultural.
Having a bloodline that is 1/2 Mediterranean in descent, the odds of my arm hair covering the face of any watch I own increases with each passing day, and not even I want to see that.
Having said all this, as we approach January 1st, 2010, a date which marks the end of Medicare's acceptance of consultation codes for reimbursement, a wrist watch could very well end up being the best friend of specialists nationwide who suddenly find themselves without a longstanding reporting tool for patient encounters.
Evaluation and management documentation guidelines state that if more than 50% of your face-to-face time with the patient is spent in counseling and/or coordination of care, the E/M service can be selected based on time.
For a specialist who invests time determining a proper course of treatment in either the office or hospital setting, this rule deserves a second look.
As an illustrative example, one problem that has presented itself is in regard to what used to be considered consultations in the hospital setting.
Physicians will now bill an initial hospital care code (CPT codes 99221-99223) upon their first encounter with the patient in the hospital.
On the surface, one can immediately see a problem, as there are 5 inpatient consultation codes, but only 3 initial hospital care codes.
Because of differing documentation standards, there is no clear crosswalk between the two code sets.
Now let's look at two of these codes for comparison.
CPT code 99252 (level 2 inpatient consultation), strictly from a documentation standpoint, requires an expanded problem focused history, an expanded problem focused examination and straightforward medical decision making.
Using Southern California in 2009 as a reimbursement benchmark, CPT code 99252 is listed in the $81 range.
Compare that to CPT code 99221 (level 1 initial hospital care).
This code requires either a detailed or comprehensive history, a detailed or comprehensive examination and straightforward to low medical decision making.
Using the same reimbursement benchmark, 99221 is listed at around $96.
Now on the surface, it appears that the documentation standards work against the specialists if given the choice between the two codes, but let's add the documentation of time spent in counseling and/or coordination of care into the mix.
The average total time for a 99252 is 40 minutes, but the average total time for a 99221 is 30 minutes.
The lesson taken away from this is that an awareness of the time you are spending with the patient could lead to less of an investment of total time, but for a higher reimbursement.
Before jumping headlong into time-based billing, it is in the physician's best interests to remember the two most important things with regard to documenting for this type of code selection.
First, the medical decision making portion of your E/M documentation must detail the counseling and/or coordination of care.
It is not enough to use generic statements such as "Spoke w/ Dr.
X" or "Orders written".
The documentation must include the results of that conversation and detail about the physician's care orders for the patient.
Second, and most importantly, your time caveat statement must show that more than 50% of the total encounter time was spent in counseling and coordination activities.
This can be stated either by using the exact minutes or as a clear statement of percentages.
Good examples of this are:
  • I spent 50 total minutes with the patient, 30 minutes of which were spent in counseling and coordination of care.
  • I spent 50 total minutes with the patient, more than 50% of which were spent in counseling and coordination of care.
Documentation that simply states "I spent 30 minutes with the patient" is insufficient for choosing your CPT code based on time.
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