With the new 2021 E/M coding guidelines for office visits and most recently, the new 2023 E/M coding guidelines for inpatient services published by the AMA and approved by CMS, we find many providers, nationwide, billing based on Total Time instead of Medical-Decision-Making (MDM). The definition of time was changed to total time spent in approved activities performed on the same calendar date as the face-to-face visit. This represents Medicare’s movement towards recognizing the provider’s work involved in non-face-to-face services such as care coordination. This only applies when code selection is based on time and not MDM.
However, it is important to note that medical necessity still needs to support the amount of time spent on activities concerning the patient. There are certain activities that are not included in time such as social conversation with the patient, clinical staff time, activities performed on a different calendar date such as the day before or after the face-to-face encounter along with travel time.
There is no rule that states that you must provide a time for each activity, but you must include a list of activities performed to support the amount of time documented. It is not reasonable to believe that your statement will be the same for each encounter with the same patient. For instance, you may have reviewed the notes in Care Everywhere within Epic on the first day you saw the inpatient but not for subsequent visits. If this is the case, your time statement will not include this information. You may find that the activities you perform each day are different. Be sure your time statement reflects this. The activities performed must be an accurate account for each encounter.
Think about the actual time that is being documented. It is understood that time can be difficult to keep track of. Do the best you can and when in doubt, err on the side of caution. Are you always documenting the exact amount of time necessary to get to the higher level of service? For instance, are you always documenting 40 minutes for 99215 or 80 minutes for 99255 when in fact you have more time and maybe in some cases are a minute or two short? Be sure to document time appropriately. Maybe you spent 45 minutes or 50 minutes in some cases and other cases may have only 38 minutes. The applies to any E/M service you are selecting based on time.
Key points to remember:
- Medical Necessity must support the time spent on approved activities.
- Track and document the time spent on approved activities as best you can.
- The time statement should include the activities performed for each encounter.
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