We’re in a full year now on the new documentation guidelines for Evaluation and Management Services.  It has been a learning experience and most of us are getting it figured out.  The biggest issue MSF is seeing is due to the changes in the way time is used to determine the level of service.  The changes affect code range 99202 – 99215.

Total Time spent – (Codes 99202-99205 and 99212-99215):

When using time as a basis for code selection, use the total time on the date of service only.  Time includes both the face-to-face and non-face-to-face time that is personally spent by the physician and/or other qualified health care professionals on the day of the visit – this includes time in activities that require the physician or other qualified health care professional but not time spent by clinical staff.  Time spent on activities that are separately billable are also not included.  Counseling and coordination of care no longer has to dominate the time spent with a patient when using time for code selection, so the statement “of which more than 50%” is no longer applicable and should not be used. 

Per AMA, time includes the following:

• preparing to see the patient (such as review of tests etc)
• obtaining and/or reviewing separately obtained history
• performing a medically appropriate examination and/or evaluation
• counseling and educating the patient/family/caregiver
• ordering medications, tests, or procedures
• referring and communicating with other health care professionals (when not separately reported)
• documenting clinical information in the electronic or other health record
• independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
• care coordination (not separately reported)

Time does not include the following:

• the performance of other services that are reported separately (such as xrays, minor procedures, labs etc)
• travel
• teaching that is general and not limited to discussion that is required for the management of a specific patient

Time Ranges for CPT codes 99202-99215:

Prolonged time codes 99354 – 99359 can no longer be used with the above codes for services on the same day.   Two new codes (99417/G2212) may be used with 99205 and 99215. 

When using 99417 – providers must spend at least 15 minutes beyond the minimum time listed for 99205/99215 and documentation needs to support services where the time was spent.

When using G2212 – providers must spend at least 15 minutes beyond the maximum amount of time listed for 99205/99215.  This is the only code that Medicare will accept for prolonged services with 99205/99215. 

Total Duration of New Patient Office or Other Outpatient Services (use with 99205):

Total Duration of Established Patient Office or Other Outpatient Services (use with 99215)

Medical necessity is still the overarching criteria for the level of service – which includes the decision making process of the care provider in addition to the requirements of the CPT code. 

Click for a helpful publication put out by the American Medical Association (AMA) and CMS .   Other resources are the CPT Manual and Medicare.