The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Defining Time for E&M Codes
Challenges abound when utilizing time as a deciding factor for Evaluation and Management Codes (E&M). Unfortunately, CMS guidelines are inconsistent on how to meet time requirements and on how to document the time in a compliant manner. For E&M services, the typical published time for the code must be met or exceeded in order to select that code based on counseling and coordination rules. The Prolonged Service first-hour codes have a threshold of 30 minutes. As a result, the code is actually for 30-60 minutes. The Prolonged Service code that is for each additional 30 minutes (beyond the first 60), is selected at minute 61, according to CPT. To this end, one minute into the 30 minute block of time for the code allows its use. According to CMS, “The duration of counseling or coordination of care... may be estimated, but that estimate, along with the total duration of the visit, must be recorded.” For Prolonged Service codes start and stop times are required. It is suggested that you always document start and stop times, your billing staff can apply the differing rules. This documentation proves not only that you met the code requirement, but it also shows when in the day your services were provided, if needed on an appeal for payment.