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 is, but 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:
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 OBSERVATION CPT® CODES TIME THRESHOLD REFERENCE TABLES
HOSPITAL SAME DAY ADMIT/DISCHARGE CPT® CODES TIME THRESHOLD REFERENCE TABLE
CLINIC/OUTPATIENT CPT® CODES TIME THRESHOLD REFERENCE TABLES
CRITICAL CARE CPT® CODES TIME THRESHOLD REFERENCE TABLE (MAY BE USED AT ANY SITE OF SERVICE BY ANY PHYSICIAN)Is there an easier way to stay in compliance with archaic E/M rules for hospital and clinic encounters? Yes there is, but 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:
- Documentation of total time (face-to-face/floor time)
- Documentation describes the content of the counseling and or coordination of care
- Documentation supports greater then 50% of the total time spent involved counseling and or coordination of care.
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 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
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