Providers must document the complexity of care for each and every patient.

There is a standard misunderstanding of the utilization of time-based documentation and billing. Clearly, over time, many opinions and interpretations of ambiguous guidelines have clouded this topic, and it is time that we get back to the basics of truly understanding time.

First, let’s identify what we all have as our “known knowledge base” regarding time-based documentation:

  • Time should only be used when counseling and coordination of care dominated the encounter.
  • Total encounter time must be documented.
  • No less than half of the total time should have been consumed with counseling and coordination of care.
  • The documentation should reflect the amount of time that was spent discussing with the patient.

While these are the knowns, let’s ensure adequate understanding of each, based only on facts versus opinion and interpretation.

Fact: If a provider is documenting time on every encounter in an effort to create a documentation seat belt, we are not allowed to consider this in lieu of documentation guidelines. Time is not a seat belt, as it should only be utilized when counseling and coordination of care dominates the encounter.

Misinterpretation and Clarification: The time assigned to each CPT code is not a requirement of that service. As noted by the American Medical Association (AMA) Current Procedural Terminology (CPT), the word “typically” exists prior to the time definition. Therefore, you cannot look at a provider’s schedule for the day and only allow him x number of evaluation and management (E&M) encounters based on his clinic schedule. Remember: time is only to be used when counseling and coordination dominates, and only in those scenarios would we consider the time element, as it is a substitute for the documentation requirements.

Our provider must document the total amount of time spent during this encounter.

Misinterpretation and Clarification: There is currently no requirement that the provider must use “clock time” to document these services. However, in instances of reporting the encounter service along with prolonged physician services, some carriers have been known to deny services lacking this information. Unless your provider is utilizing prolonged services, then clock time would not be required.

Example: This encounter was 45 minutes long with a 72-year-old male, and during that time I reviewed with the patient conservative treatment options for their back pain, as well as consideration of pain management, rehab expectation, and potentials, and also included a conversation regarding a referral to a spine specialist for evaluation and treatment.

The provider must have spent greater than half of the encounter counseling and coordinating the care of that patient.

Misinterpretation and Clarification: There is no requirement that a physician must document a statement such as “greater than 50 percent of the time was spent on face-to-face counseling and coordination of care…” While including such a statement would be a documentation best practice, there is currently no Medicare Administrative Contractor (MAC) that requires the inclusion of such a statement. However, we would expect that when the provider documents his or her encounter, there would be less history/exam than usual, and the provider’s qualifying statement of what they spent discussing would imply this fact.

Example: In the example above, we noted that the time was appropriately documented, and based on a 45-minute encounter, at least half of that time was being spent on counseling and coordinating care; that would indicate our provider should have spent at least 22 minutes having such discussions with the patient. Because this documentation is inclusive of what was discussed, it is reasonable to support that it would take at least that amount of time.

The provider must include a statement (one to two sentences) documenting what counseling and coordination of care was provided.

Misinterpretation and Clarification: Since this statement should imply the dominance of counseling/coordination in the encounter, then we would expect our provider to not only merely provide a general statement, but to be more specific regarding what was discussed.

Example: A patient presents to the clinic today as a diabetic with uncontrolled sugars. Our provider indicated that the total encounter time was 60 minutes with the patient, and that time was spent reviewing with the patient the appropriate monitoring of sugars, the impact the patient’s diet is having on their diabetes, and the impact lack of any type of physical exercise/movement is having on the patient’s overall health. This would be appropriate documentation.

However, consider this: the next month, the patient returns and the provider documents that he or she spent 60 minutes with this patient reviewing…” In this case we should expect to see a variation from the prior month. Is it possible the education involved the same elements? Absolutely, but why would they include those same elements for a whole hour? Because the patient was not compliant. That should be the cornerstone of the time-based documentation in this follow-up encounter. The documentation should include how not being compliant has impacted the patient’s current state, how it will impact his future, and a path to modify these concerns.

Now let’s turn to the part of documentation guidance for time that is not widely discussed. In the Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual, 30.6.1.C, we are advised of the following:

“However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided.”

The key portion of the rule that is extracted above has very specific language, which many bypass upon reviewing the rules. However, it plainly states that it is time in conjunction with medical decision-making (MDM). Quite honestly, this is one of the most plain English rules we have, and it seems to exactly detail why a provider cannot document 60 minutes for a strep throat patient and suddenly bypass everything to go straight to a 99215.

If you are like me, as with the first time I read this statement, your head may be spinning as you wonder how many encounters you have audited/coded incorrectly based on this requirement. Well, probably not as many as you think, but let’s break the rule down and better understand exactly what it says – and not someone’s interpretation.

To make this make sense, I want you to think of the documentation of every single patient that comes through your doors. There is one single thing in common with any patient encounter: all will include an assessment and plan of care. Regardless of why a patient comes into your office, the provider will have a definitive plan related to that encounter. They may not have a fully developed history, they may only have vital signs as their exam, but each will have a MDM. It seems, in my opinion, that what CMS is insinuating here is that time can take the place of history and exam. Rather, it is used in lieu of it, and doesn’t that make sense? Doesn’t it make sense that if the provider spent so much time talking to the patient, he wasn’t able to complete a history and exam? But at the end of the day, that patient will still have an assessment and plan of care – and a MDM. Therefore, time in conjunction with MDM makes perfect sense.

Need more proof? If CMS’s intent was that you would assign the level of service merely based on time, then why are prolonged physician services an add-on code for any E&M level, even a 99201? Even with time-based encounters, our level of service should be determined by the lower of the time-supported codes and the MDM.

This is just one more reason why our providers must document the complexity of care for each and every patient. Documentation that is not patient- and visit-centric; it just doesn’t work anymore in our healthcare environment, leading to all of the “healthplexities” we encounter on a daily basis.

In my next article, we will further develop this concept application of the MDM in conjunction with time as we consider the “scoring process” of this portion of the encounter. 


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