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July 2016

Devil of a Time
By Lisa A. Eramo
For The Record
Vol. 28 No. 7 P. 20

Why reporting outpatient time-based CPT codes isn't as easy as it seems.

Outpatient time-based CPT codes may seem relatively straightforward, yet many organizations continue to struggle with documentation and coding compliance. Thus, these codes are generally an easy target for recovery audit contractors and other third-party auditors that can easily glean errors based on the absence of start and stop times or the incorrect calculation of total time spent.

"When it comes to audits, anything that has a greater potential to be inaccurate or abused is going to be an audit target," says Troy Abruzzo, principal at North Highland, a global consulting firm based in Atlanta.

Michael Strong, MSHCA, MBA, CPC, CEMC, a bill review technical specialist at SFM, a leading workers' compensation insurer in Bloomington, Minnesota, agrees, adding that rules may vary greatly by payer and by specific services rendered. Strong spoke about time-based codes during a packed session at the 24th annual HEALTHCON conference sponsored by the AAPC in April.

During his presentation, Strong discussed several headache-inducing codes. In addition, experts have identified other outpatient time-based codes as being particularly problematic.

Physical Medicine Services
Many of the CPT codes in section 97001–97799 are time based. "If your therapists are not documenting the time, you have no way to code those services," Strong says. "Physical therapy services have been on the Office of Inspector General's (OIG) list for years. It just goes to show you how many problems we have in this area."

Therapy codes are specific to each modality. When therapists use different modalities during one visit, they don't always document the specific time devoted to each modality, says Jill Wolf, RHIT, CCS, CHFP, a senior vice president of service excellence at VitalWare, LLC, a coding and revenue cycle software vendor in Yakima, Washington.

However, to code appropriately, coders must understand the various definitions of time that currently exist, Strong says. For example, the American Medical Association (AMA) considers a unit of time to be attained when the midpoint is passed (eg, an hour is obtained when 31 minutes or more have passed). Each time-based code requires a separate calculation of time spent.

Medicare looks at the totality of time spent across various time-based services. The agency's eight-minute rule specifies the following:

• fewer than eight minutes—report no units;
• eight to 22 minutes—report one unit;
• 23 to 37 minutes—report two units;
• 38 to 52 minutes—report three units;
• 53 to 67 minutes—report four units;
• 68 to 82 minutes—report five units;
• 83 to 97 minutes—report six units;
• 98 to 112 minutes—report seven units; and
• 113 to 127 minutes—report eight units.

As for commercial payers, some follow AMA guidelines while others use Medicare criteria.

Strong provides an example. A patient undergoes the following:

• eight minutes of exercises (97110);
• seven minutes of activities (97530);
• five minutes of manual therapy (97140); and
• five minutes of neuromuscular reeducation (97112).

This yields a total of 25 minutes of service.

Because more than one-half of the required 15-minute minimum of exercises was performed, coders using AMA guidelines should report CPT code 97110 x1. None of the other services met this requirement. However, using Medicare guidelines, coders should consider the total amount of time to be 25 minutes. According to the eight-minute rule, coders can report two units total. Therefore, they should report 97110 x1 and 97530 x1.

Regarding the Medicare guidelines, Strong says, "When both timed codes have the same number of minutes—but only one is billable—choose the one with the highest reimbursement rate. This is not incorrect reporting."

He adds that, when billing for time-based services, Medicare considers only time-based codes. For example, a patient presents for evaluation on the same day that he or she receives physical therapy. In this case, Strong says coders can't use the time spent performing the evaluation when determining the total units for therapy.

Strong provides the following additional compliance tips:

• Ensure specific documentation. What exercises were completed? On what body part were the exercises performed? How many minutes were spent per exercise? "Your documentation must support the medical necessity of not only why you did something but also what you did," Strong says.

• Know your payer guidelines. "If you wind up learning that one payer processes under one guideline, and another processes under a different guideline, communicate that with your billing staff. You're going to reduce the headaches for yourself and for the payers. Communication is key," Strong says.

• Documentation of number of units or simply citing the code definition doesn't satisfy time rule requirements.

• Report services only when they are supported by documentation and captured in a way that meets your facility's time policy.

Outpatient Visit Evaluation and Management
With outpatient visit evaluation and management (E/M) codes, coders have the option of choosing a code based on either level-specific requirements for the history, exam, and/or medical decision-making, or time. (Note: More than 50% of the time must be spent performing counseling and coordination of care.)

Although billing based on time may be more straightforward from a code assignment perspective, the method is certainly not without its challenges. "Even for E/M coding, physicians might document time in minutes, but for a coder to be able to use that time for coding purposes, it must specifically state that the time was spent face-to-face with the patient, family members, or other caregivers," Wolf says.

When billing an E/M code based on time, Strong says physicians should document the following:

• total time spent with the patient;
• time spent performing counseling and coordination of care; and
• extent of the counseling and/or coordination of care.

Critical Care Services
As with outpatient E/M visits, Strong says codes for critical care services (99291 and 99292) require specific documentation regarding the nature of services performed and the time spent rendering those services.

In particular, code 99291 (critical care, E/M of a critically ill or critically injured patient) requires clear documentation of 30 to 74 minutes of critical care. Code 99292 (each additional 30 minutes) is an add-on code that requires a minimum of 75 minutes of critical care. Per CPT, coders must report 99292 in conjunction with 99291.

Documentation for both codes must indicate an immediate threat to life or physiologic function. In addition, per CPT, a physician must devote his or her full attention and be immediately available to the particular patient during the time when critical care services are rendered. The physician cannot provide services to any other patient during the same time period. Critical care services may be performed at the immediate bedside or elsewhere on the floor or unit. The time spent performing critical care doesn't need to be continuous. Time spent performing activities outside of the unit or off the floor, such as telephone calls taken at home, may not be reported/counted as critical care because the physician isn't immediately available to the patient. Physicians also shouldn't count any time spent performing activities that don't directly contribute to the treatment of the patient, such as telephone calls to discuss other patients.

The following services are included in critical care when performed during the critical period by the physician performing critical care:

• Cardiac output measurements (93561, 93562);
• Chest X-rays (71010, 71015, 71020);
• Pulse oximetry (94760, 94761, 94762);
• Blood gases, and information data stored in computers (99090);
• Gastric intubation (43752, 91105);
• Temporary transcutaneous pacing (92953);
• Ventilator management (94002–94004, 94660, 94662); and
• Vascular access procedures (36000, 36410, 36415, 36594, 36600).

Per CPT, keep the following time requirements in mind when reporting critical care services:

• less than 30 minutes, report the appropriate E/M code;
• 30 to 74 minutes, report 99291 x1;
• 75 to 104 minutes, report 99291 x1 and 99292 x1;
• 105 to 134 minutes, report 99291 x1 and 99292 x2;
• 135 to 164 minutes, report 99291 x1 and 99292 x3;
• 165 to 194 minutes, report 99291 x1 and 99292 x4; and
• 195 minutes or more, report 99291 and 99292 (as appropriate).

Prolonged Services
When the length of time a physician spends with a patient goes beyond what is considered typical for that service, codes for prolonged services should be reported along with E/M codes. Prolonged services codes include 99354 (prolonged E/M or psychotherapy service [beyond the typical service time of the primary procedure] in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour) and 99355 (each additional 30 minutes).

Per CPT, consider the following when reporting prolonged services:

• less than 30 minutes, not reported separately;
• 30 to 74 minutes, report 99354 x1;
• 75 to 104 minutes, report 99354 x1 and 99355 x1; and
• 105 minutes or more, report 99354 x1 and 99355 x2 (or more for each additional 30 minutes).

At HEALTHCON, Strong explained that when billing an E/M code based on time, the time associated with the highest-level E/M code must first be met before time can be considered for prolonged services. If the E/M code is not based on time, then the elements for the base code must be met before time can be considered for prolonged services.

For example, greater than 50% of a 60-minute office visit is spent counseling an established patient on his diabetes, including compliance with medication and proper diet. Documentation supports the elements of 99213. However, because time is the controlling factor in this scenario, coders can actually report this service using 99215 (which is typically 40 minutes per CPT). The remaining 20 minutes don't meet the 30-minute minimum requirement for prolonged services.

However, consider this scenario: A patient arrives for her preoperative clearance for hip replacement surgery. The physician spends 100 minutes performing the preoperative exam and evaluation. Documentation supports the elements associated with 99214. Since time is not the controlling factor in this scenario, coders should report this service with 99214 (typically 25 minutes per CPT) as well as 99354 x1 and 99355 x1.

Strong reminded coders of the following important 2016 changes for prolonged care services:

• 99354 and 99356 are limited to once per date of service.

• 99415 and 99416 are new codes to denote prolonged clinical staff services with physician/other qualified health care professional supervision.

Code 99415 is for the first hour of prolonged services and requires a minimum of 45 minutes before a provider is permitted to report the first unit. Note that this is an exception to the AMA time rule that normally requires a provider to exceed the midpoint (50%) of a service. When reporting 99415, providers must exceed 75% of the time before reporting the first unit, Strong says.

• 99354 and 99356 cannot be reported with either 99415 or 99416.

Time spent performing separate reportable services other than the E/M or psychotherapy service is not counted toward the prolonged services time, according to the 2016 CPT Professional Edition.

In addition, the necessity of prolonged services is considered to be rare and unusual, according to the fiscal year 2016 OIG Work Plan, in which these services are listed as a new target area.

The biggest challenge with anesthesia is capturing the "in and out" times, particularly when an anesthesiologist is supervising certified registered nurse anesthetists, Abruzzo says.

Wolf agrees. "Most anesthesiologists are tuned in to the need to document start and stop times according to the official definitions," she says. "However, on the claim form, the biller has to enter the total minutes, which requires a calculation based on the start and stop times. This is definitely one area where automation is helpful."

At HEALTHCON, Strong reminded attendees to verify each payer's time unit standard for calculating reimbursement and to report all time in minutes on the CMS-1500. Don't convert minutes to units, he said.

Compliance Tips
When billing based on time, consider the following bits of advice to meet requirements:

Leverage IT systems to automate time-based code assignment. "The assignment occurs automatically based on what you're doing in the electronic medical record," Abruzzo says. "This ensures that the code always matches what the documentation provides. It takes a lot of the guesswork out of documentation and coding."

For example, many EHR templates prompt providers to insert start and stop times or the total time spent. "If there's a manual process for capturing that information, there's a huge potential to run into issues," Abruzzo says.

Wolf agrees. "If you have an EMR, you have these fields as structured data elements. That kind of takes care of the whole problem," she says. "With a paper record, people document that they start something and often forget to document that they stopped it."

Address physician stigma about time-based coding. "I think there's a feeling that the time isn't important from a treatment perspective," Abruzzo says. "Physicians really focus on the evaluation of the patient, assessment of the patient, their plan, and their objectives." He says organizations need to explain the importance of accurate documentation not only for billing purposes but also for patient care.

Provide rapid physician feedback. "If you really want to modify physician behavior, then you need to be able to provide that feedback very quickly," says Abruzzo, who also suggests physician champions work one-on-one with colleagues to educate them on the importance of documenting time in the medical record.

"It really goes back to the fact that for time-based codes, it all starts with provider documentation," he says. "If a hospital or other type of health care provider wants to improve time-based code capture, then provider documentation is really where you can usually move the needle the quickest. Coders know how to assign the codes. The problem is that they don't have enough information in the chart to do their job."

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.