EVALUATION AND MANAGEMENT SERVICES-TIME AS A FACTOR
When selecting an office visit code, there are only two key pathways for code selection for outpatient visit codes 99202-99205 and 99211-99215; Medical Decision Making and total time on the day of the encounter.
For this article, we will discuss time as the basis for code selection. Time is defined as the total time spent, (including non-face-to-face time) on the day of the encounter. The following activities are to be counted as E/M encounter time:
- Preparing to see the patient (eg, review of tests);
- Obtaining and/or reviewing separately obtained history;
- Performing a medically appropriate examination and/or evaluation;
- Counseling and educating the patient/family/caregiver;
- Documenting clinical information in the electronic or other health record;
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver; and
- Care coordination (not separately reported).
In Workers Compensation cases (Non-Medlegal), clinicians often receive and review extensive medical records. In the past, clinicians were able to bill procedure code 99358/99359 for the review of medical records. This code is no longer valid when perform in the same encounter as the office visit. Instead, you should use HCPCS Code G2212; Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services), to report additional time spent after the time threshold for 99205 or 99215 is met. Time spent performing other services identified by a CPT code (billable service) is not to be included.
Documentation is the key to proper reimbursement. The total time spent in the encounter needs to be documented in the medical report.
The below table includes codes to be reported when the clinician spends time beyond the threshold of codes 99205 and 99215.
Non-Face-to-face prolonged service codes 99358, 99359.
The non-face-to-face prolonged care codes are still active, billable codes. However, they may not be reported on the same date of service as 99202—99215. Use this code to report review of medical records on a separate date of the face-to-face encounter. Procedure code 99358 is to be reported for the first hour. Procedure code 99359 is to be reported for each additional 30 minutes.
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