Established Visit: Time Statement Includes Medical Assistant Time
An established 58-year-old patient with type 2 diabetes and hypertension is seen in a primary care clinic. The physician assistant (PA) documents: 'Total time on date of encounter: 42 minutes. The MA spent 15 minutes obtaining vitals and medication reconciliation; I spent 27 minutes reviewing labs, examining the patient, adjusting insulin, and counseling.' The assessment lists hyperglycemia with insulin dose increased, new bilateral foot numbness, and hypertension. The PA orders A1c, B12, and a lipid panel; prescribes gabapentin for neuropathic symptoms; and documents a moderate-complexity assessment. The coder submits 99215, citing the 42 minutes. The payer follows current E/M guidelines. The PA is credentialed and billed under the group. On audit, the compliance reviewer must decide whether the level is supported and whether the time statement can be used.
1. What E/M level is supported, and why? Address both time and medical decision making (MDM).
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The supported level is 99214, not 99215.
Time analysis: For established patients, 99215 requires 40–54 minutes of total time on the date of the encounter attributable to the billing practitioner. The note's 42 minutes includes 15 minutes of MA time, which cannot be counted. The PA's qualifying time is 27 minutes, which by time alone supports 99213 (20–29 minutes).
MDM analysis: The PA adjusted insulin for hyperglycemia (prescription drug management, moderate risk), evaluated new neuropathy, and ordered three tests. The overall MDM is moderate, which supports 99214. Under current E/M rules, the coder may select the level based on either MDM or total time, so 99214 is supported even though the qualifying time is lower.
Why 99215 fails: The 42-minute statement cannot be used because it includes non-qualifying staff time. Even if the PA had personally spent 42 minutes, the coder must ensure the time is documented as practitioner time and includes only qualifying activities. The safest correction is 99214 based on MDM, with education on time counting.
2. What documentation weaknesses could a payer challenge even if 99214 is billed?
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Several weaknesses remain:
- Ambiguous time statement: 'Total time 42 minutes' is misleading because it blends MA and PA time. A payer may treat the time as unsupported and question whether the practitioner understood the counting rules.
- MDM not broken out: The note concludes 'moderate complexity' but does not clearly separate problems, data, and risk. The prescription drug management and test orders are present, but an auditor must infer them.
- New problem not characterized: Bilateral foot numbness is listed but not described with status or prognosis. This matters for MDM and medical necessity.
- Medical necessity: Gabapentin and B12 testing should be linked to the neuropathy assessment; otherwise the payer may question the workup.
- History/exam: Although not used to select the level, the note still must support the clinical story. A template-style exam with no neuropathy-specific findings would be vulnerable.
The auditor should correct the level, educate the PA on time rules, and recommend a brief MDM template that prompts the practitioner to document the three MDM elements explicitly.
3. The claim was already paid at 99215. What corrective action and education should follow?
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The auditor should:
- Recalculate the claim at 99214 and determine the overpayment using the allowed amount, not the charged amount.
- Process a refund or adjustment according to the group's compliance policy and payer contract, and document the correction.
- Avoid labeling the error as fraud; the facts show a time-counting misunderstanding, not intent.
- Provide one-on-one education to the PA and coder on: practitioner-only time, MA time exclusion, established-patient time thresholds, and the option to code by MDM.
- Review a small sample of the PA's other 99215 claims to see whether the same time-statement pattern recurs.
- If the pattern is systemic, add a prebill edit that flags 99215 claims based on time and requires the time statement to specify practitioner time and activities.
The audit workpaper should include the original note, the corrected level, the overpayment calculation, the education date, and the follow-up sample results.