Time Threshold E/M Billing And CPT® Coding Reference Tables.

Evaluation and management CPT® coding is a set of a highly complex  rules that must be mastered for physicians to accurately submit charges for services provided.   Make sure to review the AMA CPT 2013 Standard Edition as the definitive authority on codes.    I am not a certified coding expert, but I have studied this stuff for years and have a great grasp on the E/M process.  Despite that, the rules are so complex that after a decade of hospitalist work,  I still carry a bedside E/M reference card (see at bottom of post) with me at all times to make sure I am submitting the correct E/M charge on every patient encounter, every time. 

Is there an easier way to stay in compliance with archaic E/M rules for hospital and clinic encounters?  Yes there isbut only under limited circumstances.    It is possible to submit an E/M charge that ignores all the complex rules of evaluation and management and is based on time instead.  The rules for billing based on time are much simpler.  Just three requirements are necessary when submitting E/M charges based on time spent.  The requirements are:
  1. Documentation of total time (face-to-face/floor time)
  2. Documentation describes the content of the counseling and or coordination of care
  3. Documentation supports greater then 50% of the total time spent involved counseling and or coordination of care.
If these three rules are met on your E/M evaluations, then physicians can bill based on time and not based on the complex requirements of the evaluation and management rules and regulations I have previously provided on my free E/M lecture (first link above).

Naturally, one asks the question, how much total time is required for each of the common inpatient and outpatient E/M codes?  While these time thresholds have been previously defined for most CPT® codes, some observation and same day admit/discharge codes have just recently been given time threshold values.    That means these codes too can now be used for time based billing.    Below are time threshold tables I have provided as reference for you.

These E/M hospital and office/clinic time threshold tables describe how much total minimum time is required to use time based billing and coding for commonly used inpatient, observation and outpatient/clinic E/M codes .  Use these time threshold tables as a reference when you are providing greater than 50% of your total evaluation for counseling and or coordination of care so you know which code you can use to remain in compliance.  That way you can bypass all the complex E/M rules and bill just based on time and counseling or coordination of care

On each E/M code below, if you have met the described time threshold (requirement #1 above) and your documentation supports at least 50% of that time was spent in counseling and or coordination of care, than you can bill the patient's insurance company for that  CPT® based on counseling services and time and you can ignore all the other complex documentation bullets necessary outside of the time based billing evaluation.   

HOSPITAL INPATIENT CPT® CODES TIME THRESHOLD REFERENCE TABLES

Inpatient Admit/Initial Evaluation 30 min 50 min 70 min
99221    XXX
99222    XXX
99223    XXX

Inpatient Follow-up Evaluation      15 min 25 min 35 min
99231    XXX
99232    XXX
99233    XXX

Inpatient Consult (nonMedicare as Medicare does not recognize consult codes anymore) 20 min 40 min 55 min 80 min  110 min
99251  XXX
99252  XXX
99253  XXX
99254   XXX
99255   XXX

Inpatient Hospital Discharge 30 min or less > 30 min
99238            XXX
99239           XXX

Inpatient Prolonged Service Evaluation 30 min-74 min of add on time 75 min-104 min of add on time
99356 (add on code; time here is above and beyhond the defined time threshold for base CPT® code)            XXX           XXX
99357 (add on code; time here is above and beyhond defined time threshold for base CPT® code + 99356)           XXX

HOSPITAL OBSERVATION CPT® CODES TIME THRESHOLD REFERENCE TABLES

Observation Initial Evaluation     30 min 50 min 70 min
99218    XXX
99219    XXX
99220    XXX

Observation Follow-up Evaluation ((for Attending) 15 min 25 min 35 min
99224    XXX
99225    XXX
99226    XXX

HOSPITAL SAME DAY ADMIT/DISCHARGE CPT® CODES TIME THRESHOLD REFERENCE TABLE

Same Day Admit/Discharge Evaluation 40 min 50 min 55 min
99234    XXX
99235    XXX
99236    XXX

CLINIC/OUTPATIENT CPT® CODES TIME THRESHOLD REFERENCE TABLES

Outpatient New Patient Evaluation 10 min 20 min 30 min 45 min  60min
99201  XXX
99202  XXX
99203  XXX
99204   XXX
99205  XXX


Outpatient New Patient Consult (nonMedicare as Medicare does not recognize consult codes anymore) 15 min 30 min 40 min 60 min  80 min
99241 XXX
99242 XXX
99243 XXX
99244 XXX
99245  XXX

Outpatient Established Patient Evaluation 5 min 10 min 15 min 25
min 
40
min
99211 XXX
99212  XXX
99213  XXX
99214 XXX
99215 XXX

CRITICAL CARE CPT® CODES TIME THRESHOLD REFERENCE TABLE (MAY BE USED AT ANY SITE OF SERVICE BY ANY PHYSICIAN)


Critical Care Evaluations 30-74 min 75-104 min 105-134 min 135-164 min  165-194 min
99291  XXX
99291 + 99292  XXX
99291 + (99292 x 2)  XXX
99291 + (99291 x 3)   XXX
99291 + (99291 x 4)   XXX

TOBACCO/SMOKING CESSATION CPT® CODES TIME THRESHOLD REFERENCE TABLE  (MAY BE USED AT ANY SITE OF SERVICE BY ANY PHYSICIAN)

Smoking/Tobacco Cessation Evaluation 3-10 min >10 min
 99406            XXX
99407           XXX

Make sure to review my wealth of practice management information available in my hospitalist resource area. 

LINK TO HOSPITAL CODING CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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