Time-based CPT codes are just that: time-based. Yet, more and more payers are recouping dollars from providers who most likely are doing the work but not documenting their time appropriately. If you are reporting any CPT code where time is indicated in the code descriptor, it is important to clearly document the time spent providing the service.
Services such as psychotherapy, physical and occupational therapy, and critical care and discharge day management are reported using time as the determining factor, yet many providers are experiencing payer review and possible recoupment of claims paid solely for lack of total time documented. Wisconsin Physicians Service has noted Comprehensive Error Rate Testing (CERT) errors assessed due to simply missing documentation of time spent with the beneficiary for physical medicine and rehabilitation, critical care and discharge day management services.
Medicare and commercial payers may request a refund of any payment made for time not being documented appropriately.
In March 2014, Centers for Medicare & Medicaid Services alerted providers about accurate documentation of psychotherapy services regarding the documentation of time requirements. CERT examined samples of paid Medicare claims to determine if they were properly reimbursed and found many improper payments were made.
Similarly, Prolonged Service codes 99354 and 99355 require the documentation of total time spent in the office or other outpatient setting requiring direct patient contact, whereas CPT 99356 and 99357 require the documentation of total time spent in the inpatient or observation setting requiring unit or floor time. Upon review, Medicare requires documentation of the duration and content of the medically necessary services in the medical record. CMS advises documenting the start and end times of a visit, along with date of service.
Critical Care services (CPT 99291 and 99292) are time-based services, per day, for providers delivering medical care for critically ill or injured patients. “The duration of critical care services is the time the physician spent evaluating, providing care and managing the critically ill or injured patient’s care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient,” according to the Medicare Claims Processing Manual.
Hospital Discharge Day Management services (CPT codes 99238 and 99239) only differentiate between services lasting 30 minutes or less and those lasting more than 30 minutes. If there is no documentation to support that the total duration of time spent by the discharging provider was more than 30 minutes, then the use of the code is not supported.
Time-based therapeutic procedures, exercises and other activities listed under Physical Medicine and Rehabilitation also require the amount of time spent. Breaking out the time spent in each activity or exercise is crucial for accurate billing. Medicare and some commercial payers have adopted the ‘eight-minute rule’ for time-based services. A minutes chart (see Table 1) can guide therapists to report the correct number of units for the number of minutes spent performing services.
Time has become a popular component for billing Evaluation and Management Services (E&M) as well. The three key components for E&M services are: history, physical exam and medical decision-making. However, if the provider is billing based on time, there are no specific documentation requirements for the three key components. If using time as the controlling factor in determining the level of E&M service, the provider must document the time spent face-to-face with the patient and that at least half of that time was used for counseling and coordination of patient care. Additionally, the nature and extent of the counseling and coordination must be documented.
Documented phrases such as “a lengthy conversation” or “an extended amount of time was spent” do not qualify for time-based billing because they do not adequately quantify the time spent. What is determined as an extended amount of time to one might mean something entirely different to another. Following with the golden rule of coding, “if it isn’t documented, it didn’t happen.”
MGMA members, in recent months, have reported sticky audit and review scenarios with commercial payers due to the improper reporting of time for time-based services. Don’t let time, or lack of it, be the enemy in your efforts toward excellent documentation and coding standards in your practice.
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