Break down face-to-face time in 99000 code documentation

Last month, we reviewed the coding quandary of patients who have allergies. We discussed that with 92000 codes, the exam documentation requirements are different than with 99000 codes and that if you chose to bill the exam as a 99000 code, the level of history, exam and decision-making must meet very specific criteria to justify the level of coding. (For the complete resource, see go.cms.gov/2I8zOy2 .)

This month, we’ll build on this by reviewing a CMS guide for Evaluation and Management (E/M) Services, available at the same link above, and how to appropriately code for face-to-face time using a 99000 code.

ASSESS THE DOCUMENT

The exact terminology below can be found on p.40 of the CMS guide.

In the case in which counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

QUALIFYING FACE TIME

The CMS requirement for utilizing face-to-face time with the patient has somewhat changed (favorably to providers) in terms of the documentation requirements and types of services that qualify before, during and after the patient appointment occurs. For example, if you have a patient who has AMD and you spend (as is often appropriate and necessary) extensive time explaining to the patient his retinal findings. This may include reviewing treatment options, such as supplementation and proper nutrition, and then detailing for the patient his best and worst case scenario for the disease. You can then include this amount of face-to-face time in calculating the level of 99000 code you would use for billing purposes and defend your billing, should you be audited.

However, please remember face-to-face time does not include the time it takes for you to examine the patient. It is used as a quality measure provided to the patient and is defined as time spent performing coordination of care, counseling, planning and the treatment needed for the patient, their care-giving family members or other healthcare providers.

As another example, you would not use the higher coding simply because a particular patient examination process, such as testing, takes longer to perform.

DOCUMENT IT

Bottom line: Time can justify the use of a higher-level E/M reimbursement code. One might ask then, how does the insurance company know what I did to justify the face-to-face time?

As always, remember the saying: “What isn’t documented in the chart wasn’t done.” Use the exact words found in the definition to document what you spent time doing, who you spoke to (e.g. patient, family member, other physician), and make it clear to the auditor so that, in the case of an audit, you will have no issues. OM

DR. JASPER practices in West Palm Beach, Fla.. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at dr@apriljasper.com.