The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However we will still need to use them when auditing notes from before 2023.
This article does not apply to services performed after 1-1-2023.
Use these rules when billing for codes that use the 1995/1997 guidelines.
- You can use time to select Evaluation and management codes if typical time is listed for that code in the CPT® book and the visit is predominately counseling and coordination of care. Document the total time of the visit, the fact that more than 50% of the visit was counseling and the nature of the counseling.
- Emergency department visits do not have typical time listed, and time may not be used to select the level of ED visit. Three of the three components (history, exam and MDM) are required.
What codes continue to use 1995/1997 rules?
- Hospital services, 99221–99233
- Consultations, 99242–99255
- Home visits, 99341–99350
- Observation care, 99218–99220, 99224–99226,
- Observation or inpatient hospital care 99234–99236
- Domiciliary care, 99324–99337
Documentation requirements | Using time to select the code
- For time based codes, document time in the medical record, not just the billing record
- Counseling/coordination of care must “dominate” the visit, that is, must be more than 50% of the encounter
- For outpatient consults, home visits and domiciliary care, more than 50% of the face-to-face time must be in counseling or care coordination; for facility visits, more than 50% of the unit time
Counseling is discussion with patient and/or family regarding:
- Diagnostic results, impressions, recommended diagnostic studies
- Risks & benefits of management
- Instructions for management
- Importance of compliance
- Risk factor reduction
- Patient and family education
Key points when using time to select a CPT® code
- Document time in the medical record when time is used to select the service.
- For E/M services in which time is the determining factor, document the total time of the visit, the fact that more than 50% was spend in counseling, and the nature of the counseling. Select your level of service based on the total time.
- For prolonged services, select the level of E/M code that you provided and documented. If your total time spent with the patient was 30 minutes more than the typical time, you may add on a prolonged services code. Document the total time. use the chart to select the code. If the visit is entirely counseling, select the highest code in that category (if time spent) before adding the prolonged services code.
What to document for codes
- Total time for the visit (provider, not staff time)
- Statement that more than 50% of the visit was counseling or coordination of care
- Description of the nature of the counseling
Remember, codes 99202–99215 no longer follow this guidelines.
Internet Only Manual, Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 126.96.36.199
Starting January 1, 2021, 99354 and 99355 may not be reported with codes 99202–99215.
Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)
each additional 30 minutes (List separately in addition to code for prolonged physician service
Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)
each additional 30 minutes (List separately in addition to code for prolonged physician service)
Bill an E/M and prolonged or just an E/M based on time?
- If the visit is 100% counseling, bill an E/M based on time. Add prolonged services only when the threshold time for the highest level of code plus 30 minutes is met
- If the visit has history, exam and MDM components, bill an E/M based on the level of service, and add a prolonged code if the total time is 30 minutes more than the typical time for the code.
Download the Definitive Guide to Using Time to use as a handy quick reference.
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