Question: Is it risky to use time for an E/M note?
Answer: It depends.
Let’s start with the facts:
- Practitioners may use time or MDM to select a level of E/M service.
- There is no modifier. The claim looks exactly the same to the payer whether the physician or non-physician practitioner (NPP) used time or MDM. The payer doesn’t know if time or MDM was used to select the code unless they request records.
- Physicians and NPPs sees Medicare, Medicaid and commercial patients over the course of a day or week, so an individual payer won’t receive all the claims for that day and say, “Wow. 20 level 5 visits in one day.”
But
- Payers track E/M frequency by specialty. If the physician or NPP reports significantly more high-level services than other physicians of their specialty, that could trigger a request for records or an audit. The payer collects this data.
- If a payer reviews records, it is likely that all the records will use the same, templated time statement. We use EHRs. It’s inevitable. But, can a reviewer tell what happened at the visit? Does the note say that the patient and family members had a lot of questions? Does the record note extensive record review with a brief summary of what was in those records or labs or images? Reviewers look for something in the note that explains the time spent, beyond the templated statement.
Internal review
More frequent than a payer audit is an internal review. A coder, auditor or another practitioner noticing a pattern. In the decades I’ve worked with physicians and NPPs, (I’m omitting the number of decades) I’ve encountered this issue a handful of times. Not frequently. One physician added prolonged care to every visit, and there weren’t enough hours in the day. Critical care services all noted as “Over 30 minutes spent.” (Okay, that was frequent in the past.) A staff member who said to me once, “40 minutes! She’s never in the room for 40 minutes!” I want to emphasize that these were rare occurrences.
But, auditors and coders alike beg clinicians to immediately stop writing “At least 40 minutes was spent.” “I spent over 40 minutes.” Or, using a favorite time for every note. “I spent 43 minutes.” We can’t expect stop watch accuracy. Some EHRs may have tools that help, but the nature of healthcare is that not all the work related to an encounter always happens in a continuous time period.
If we don’t want the practitioner to say “Over 55 minutes was spent,” what do we want them to say? I suggest two things. Ask the practitioner to estimate their time, when the visit is going long. If it’s a patient you know takes more than the usual time, notice what time you entered the room. If you’re in the room and you can see, this is going to be a long visit, notice the time then. Then, track your post visit time. In the note, say in plain English what took so long. “Betsy’s sister was with her at today’s visit, and they both had many questions, which were answered.”