Use these rules when billing for codes that use the 1995/1997 guidelines. In 2021, this does not include codes 99202–99215.
What codes continue to use 1995/1997 rules?
- Hospital services, 99221–99233
- Consultations, 99241–99255
- Observation care, 99218-99220, 99224–99226,
- Observation or inpatient hospital care 99234-99236
- Home visits, 99341–99350
- 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.
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 22.214.171.124
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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