I made a mistake recently when I spoke to a group of hospitalists, and although I’m embarrassed to admit it, admit it I am. I was asked if the time spent coordinating care on the floor out of the patient room could be used when selecting an inpatient service. I incorrectly said that over half of the total time had to be face-to-face with the patient. This was wrong! I confused office/outpatient rules with inpatient rules. I have since gone back to CPT and the CMS manual and to their Medicare Contractor, NGS and corrected it in writing. In case any of you have a similar moment of confusion, here’s what I found, with citations.
Summary: A physician, NP or PA may use time to select an inpatient or observation code when more than half of the total unit time is spent in counseling or coordination of care. Although it could be face-to-face counseling, the coordination of care does not have to be done face-to-face.
What needs to be documented: total time on the unit and that over half was in counseling. “I spent xx minutes on the unit caring for the patient, over half in counseling/ coordination of care.”
From CPT: Unit/floor time (hospital observation services, inpatient hospital care, initial inpatient hospital consultations, nursing facility): For reporting purposes, intraservice time for these services is defined as unit/floor time, which includes the time present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time to establish and/or review the patient’s chart, examine the patient, write notes, and communicate with other professionals and the patient’s family.
From the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 C
In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.
The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.
From NGS: (I have removed the references to office based services)
Time-Based Evaluation and Management Services
The National Government Services Medical Review Department is currently performing service-specific prepayment audits on several families of E&M services as well as prolonged services.
Medical review results indicate that in some cases, when time-based codes are billed, the amount of time involved is missing completely from the documentation. In other cases, the records may specify the amount of time involved but lack documentation detailing what was actually done during that time. The purpose of this article is to assist in improving documentation so that it supports the billed services.
It is essential that the documentation specifically state the amount of time involved in the service. Simply stating, for example, that you had a “lengthy discussion with the patient” is imprecise and subjective.
The preferred practice is to include clock times or start and stop times in your documentation, (e.g., “03/09/2008 3:15–3:55 p.m.”). In certain instances where this is not feasible, such as in inpatient settings where the total time is not continuous, a summary of time, or total time spent is acceptable.
Counseling and/or Coordination of Care
Only when counseling and/or coordination of care constitute more than 50 percent of the floor time, will time be the key or controlling factor in E&M code selection.
Documentation in support of these services should include the following:
- Total duration of floor time.
- The duration of counseling or coordination of care and medical decision making.
- A detailed description of the coordination of care or counseling provided. The documentation needs to provide sufficient information on what was coordinated and what was discussed or advice provided during counseling. Simple references such as “chart reviewed, RN consulted, reviewed Rx, etc.” is not sufficient.
The physician need not complete a history and physical examination in order to select the level of service. Time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.
Special thanks to my friend and colleague Shelley Watts, who helped me sort this out.
Codes: 99221–99223, 99231–99233, 99218–99220, 99224–99226, 99234–99236.