E/M Level Selection for Complex Visit
A 58-year-old established patient presents with worsening shortness of breath and chest tightness. The physician performs a detailed history (chief complaint, extended HPI, 10-system ROS, and 2 past medical/family/social history items), a detailed examination (12 systems), and medical decision making of moderate complexity (prescribes a new antiarrhythmic, orders an ECG and chest X-ray, and discusses risks/benefits). The physician spends 45 minutes total on the date of the encounter, including 20 minutes of face-to-face time and 25 minutes of pre- and post-visit work (reviewing prior records, interpreting ECG, and coordinating care with a cardiologist). The patient is insured by Medicare. The practice uses 2021 E/M guidelines for office visits.
1. Which E/M code should be reported and why? Consider both MDM and time-based coding.
Read the worked answer
Under 2021 guidelines for established patient office visits (99211-99215), the level can be selected based on either MDM or total time on the date of the encounter. Here, MDM is moderate (prescription drug management, ordered ECG and chest X-ray, and discussed risks/benefits). Moderate MDM supports 99214. Time: total time is 45 minutes, which for 99215 requires 40-54 minutes. However, time-based coding requires that the time be spent on the date of the encounter and includes both face-to-face and non-face-to-face activities performed by the physician. The 45 minutes includes 25 minutes of pre- and post-visit work, which is allowable if it is on the same date and directly related to the encounter. But note: Medicare requires that time-based coding be used only when counseling and/or coordination of care dominates the encounter (though the 2021 guidelines removed that restriction). However, the time must be documented. If the physician documented 45 minutes total, then 99215 could be supported by time. But since MDM is moderate, 99214 is also supported. The coder should review the documentation to ensure the time is accurately recorded and that the activities meet the definition. If both MDM and time support a level, the coder may choose the highest level that is supported. However, there is a risk: The 25 minutes of pre- and post-visit work may not be counted if not performed by the physician? Actually, the guidelines say 'total time spent by the physician and other qualified health care professionals on the date of the encounter' for the E/M service. So it can be counted. But the coder must ensure that the time is not double-counted with other services (e.g., ECG interpretation is a separate service with its own code). The ECG interpretation is included in the E/M if it is part of the E/M? No, ECG interpretation (93000) is separately reportable if performed and documented. The 25 minutes includes interpreting ECG, which is a separate service; that time should not be included in the E/M time. Therefore, the time for E/M should be reduced by the time spent on separately reportable services. So total E/M time might be 45 - (time for ECG interpretation) = less than 40, making 99214 by time. Thus, 99214 is supported by MDM and possibly by time if adjusted. Recommend 99214.
2. What are the documentation requirements for time-based coding, and how should the coder handle the ECG interpretation?
Read the worked answer
For time-based coding, the physician must document the total time spent on the date of the encounter, including both face-to-face and non-face-to-face activities. The documentation should specify the activities and the time. However, time spent on separately reportable services (e.g., ECG interpretation) should not be included in the E/M time. The coder should review the documentation to identify time spent on the ECG. If the physician documented '45 minutes total, including 10 minutes interpreting ECG,' then subtract 10 minutes, leaving 35 minutes, which supports 99214 (30-39 minutes). The coder should also ensure that the ECG interpretation is separately reported with the appropriate code (e.g., 93000) if it meets the requirements for a separate service. If the ECG is performed in the office and the physician interprets it, it is separately reportable. The coder should not count that time toward the E/M.