Time Is Money: The Ins and Outs of Time-Based Coding
Key takeaways:
Evaluation and management (E/M) codes may be based on medical decision making (MDM) or time spent caring for the patient.
When caring for complex patients who need time-intensive management, time-based billing allows the provider to capture reimbursement for the work performed.
Documentation must be detailed and support the level of billing and coding.
The biggest change in how to code for healthcare services since 1997 took place at the beginning of 2021. With this change, healthcare providers (HCPs) now have a choice on how they bill for evaluation and management (E/M) services. A visit can be coded according to medical decision making (MDM) or time spent caring for the patient on the day of their visit.
Before, time-based coding could only be used if over 50% of the time spent face-to-face with the patient was spent on counseling and coordination of care. Time spent outside the face-to-face encounter could not be captured. Now the 50% rule does not apply at all. And time spent in activities, like coordinating care spent outside the exam room, can be captured for billing.
But does it make sense to code based on time, and is it worth the effort required? Let’s explore the requirements for time-based coding, and when it can be used to your advantage.
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The evolution of billing
The need to develop standard methods for the practice of billing and coding resulted in the United States Congress meeting in 1995 — and again in 1997 — to determine guidelines for E/M services billed to the Medicare and Medicaid programs. Private payers followed the guidelines as well.
Prior to the more stringent guidelines, billing level was typically tied to the number of diagnoses listed for the patient encounter. The more diagnosis given, the higher the visit level. Based on the 1997 requirements, the 1995 and 1997 guidelines' major difference was that additional elements to support the history of present illness and examination sections were required in the documentation. For many providers, documentation that support billing levels depended on checking the right number or boxes in the appropriate chart sections to arrive at the finalized code.
The 2021 changes aimed to reduce the administrative burden of documentation needed to support billing levels and to increase the time providers could spend caring for patients. In the new guidelines, history and physical exams are no longer used to calculate the E/M code level. However, they should still be documented as medically appropriate.
MDM vs. time-based coding
Typically, E/M coding is based on MDM. MDM requires three key components:
History
MDM
Physical examination
Four levels of MDM are possible, which include:
Straightforward
Low
Medium
High
Within the levels of MDM, three core elements are considered:
The amount of data to be reviewed and analyzed
The number and complexity of medical problems
The risk of problems and/or morbidity and mortality
Time-based coding is based solely on the time spent on the day of the encounter. It can also include time that is not face-to-face.
The time breakdown of E/M codes is shown in this chart:
| Visit level | New patient code | New patient time | Established patient code | Established patient time |
| Level 2 | 99202 | 15-29 minutes | 99212 | 10-19 minutes |
| Level 3 | 99203 | 30-44 minutes | 99213 | 20-29 minutes |
| Level 4 | 99204 | 45-59 minutes | 99214 | 30-39 minutes |
| Level 5 | 99205 | 60-74 minutes | 99215 | 40-54 minutes |
For even longer visits that exceed these times, code 99417 is reported to private payers, along with code 99205/99215 for every 15 minutes of additional time spent. Medicare, however, recognizes the code G2212 to report prolonged services. This code is used only when time beyond level 5 is exceeded by 5 to 15 minutes or more. So at least 69 minutes for an established patient or 89 minutes for a new patient.
What’s included in total time?
The 2021 change means that a visit can be coded based on total time spent caring for the patient. Before this, only face-to-face time could be captured and over 50% of the visit needed to be spent in counseling or coordination of care. Now, HCPs can capture time-intensive activities that are spent on caring for complex patients. This is exciting news for HCPs who spend a lot of time on activities like care coordination.
So what activities are applicable to billing? Examples include:
Calls to other clinicians to discuss the case
Care coordination
Chart review and prep
Counseling and education for the patient, family, or caregiver
Documentation
Getting and reviewing separately obtained history
Independently interpreting results not reported separately and communicating to patient, family, and caregivers
Ordering medications
Ordering tests or procedures
Performing the exam and evaluation
Provider time to review nurse, medical assistant, or scribe documentation
Referring and communication with other HCPs
Special considerations
The most important caveat regarding time-based billing is that all activities considered in the total time must occur on the date of service. So you can’t delay phone calls or charting for a later date if you bill based on time.
Additionally, all activities considered in the total time must be performed by a qualified healthcare professional (QHP). Medical assistant documentation will not count toward the total time. But the time it takes a QHP to review the documentation does. QHPs are HCPs that hold a level of education, training, or certification to perform professional services within their scope of practice and independently bill for that service. This differs from clinical staff, who must be supervised by a QHP.
QHPs include:
Clinical social worker
Certified nurse specialist
Certified nurse midwife
Certified registered nurse anesthetist
Doctor of osteopathy
Medical doctor
Nurse practitioner
Physician assistant
Physical therapist
However, total time can be shared between multiple QHPs. So if both a nurse practitioner and a medical doctor see the patient, they can account for the time spent by each QHP toward the total time.
Finally, you may not include time for services that are separately reportable. For example, the time required to interpret an electrocardiogram (ECG). Because a separate Current Procedural Terminology (CPT) code will be reported for the procedure, it can only be captured once.
Which way should I code?
For most HCPs, MDM coding will remain the primary method for billing. But in some circumstances, billing by time has an advantage. The end goal is to bill the highest level that your documentation can support. Higher-level visits equal a higher level of reimbursement. So it’s to your advantage to bill a higher level as long as you can provide the documentation to support the level.
New or complex visits that require time for counseling, care coordination, review of charts, and testing are usually best coded by time. Follow-up visits and single problem visits — like those for an upper respiratory infection — remain best coded by MDM. These visits still involve complexity and risk. But they don’t have the time complexity to meet a higher visit level.
Example scenario
Consider the following example, a patient transferring to your care has a history of abdominal pain and diarrhea. They have been diagnosed with irritable bowel syndrome. You have obtained their health records from their previous primary care provider (PCP). And you spend 25 minutes before the visit to review them. You spend another 20 minutes in the exam room, obtaining the patient’s history, performing a physical exam, and discussing dietary habits and recommendations. After the patient leaves the clinic, you spend an additional 25 minutes charting and arranging for a referral to see a gastroenterologist. The total time spent on this patient is 70 minutes. This equates to a level 5 (99205) new patient visit.
If the same visit were coded using MDM (1 chronic illness without change), the visit level would be 4 (99204) or moderate complexity. In this case, because of the extra time spent looking over records, counseling the patient, and arranging a follow-up, billing by time will lead to a higher visit level.
If the same patient returns for a follow-up visit and all their symptoms have improved and no further referrals are needed, this visit will be best billed using MDM. This is because the visit is less time consuming than the first one. And so, it doesn’t require much work once the patient leaves.
Tips to meet time requirements
If you choose to bill a visit based on time, there are a few ways to make sure you record all relevant activities and that your documentation supports the time billed. Here are some steps you can take:
Keep your notes open. In general, delaying completion of notes is not recommended. But if reviewing records requires additional time or you know you’ll need to consult with another HCP, keeping your notes open until you can determine if the additional time will change the visit level may be appropriate.
Record visit times. Many electronic health record (EHR) systems have timing systems. If your system includes one, make sure the chart note is open and the timer is running whenever you are performing qualified activities. If your system doesn’t have this feature, it’s worth looking at your clock and tracking time manually.
Consider activities that have a base time associated with them. For example, if you need to check a Prescription Drug Monitoring Program as part of your assessment and you know it usually takes more than 2 minutes to perform this activity, you can record that time. You can assign a base level time to other activities, like filling out FMLA paperwork.
Avoid generic documentation. Reimbursement requires that you accurately account for all time. Consider inserting a text field in your EHR that reads, “a total of ____ minutes was spent on this visit.” Then list specific activities that were performed, such as counseling patients on certain topics, ordering specific tests, adjusting medications, and documenting findings in the chart note. These details may seem tedious but will protect you in the event of an audit.
Be mindful of your total time documented for the day. If the total time you’ve documented that you spent seeing patients in a day exceeds the number of hours you worked, it will raise red flags for an auditor.
The bottom line
Time-based coding gives HCPs an opportunity to be reimbursed for the time-consuming activities required in caring for complex patients. It takes a little extra effort to accurately capture the time and document the required information, but the result is increased reimbursement for your time. For now, MDM billing will remain the coding method for most visits. But time-based coding can sometimes improve your opportunities for reimbursement.
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