There are 4 key components to medical coding. They include the exam, history, medical decision making, and time spent with the patient. Today we will discuss how time can affect your medical coding.

The Centers for Medicaid and Medicare Services offer guidelines for documenting time with a patient. These guidelines specify that any case in which counseling or coordination of patient care dominates the physician’s encounter with the patient/family, time is considered the key factor that qualifies a given level of E/M services. This means that if 50% or more of the care provided involves face to face interaction, it qualifies.

Physicians should document the total length of time of an in-person encounter or floor time, as well as the time spent counseling or coordinating care.

Face-to-face time with a patient, is the basis for defining the time in either the outpatient setting or office. All-time invested in the review of tests and records, arranging additional services, and coordinating with the patient or other professionals aren’t considered face-to-face time. These hours are therefore not considered billed time for management service or evaluation. This includes all written reports and telephone contacts.

Unit or floor time is the determining factor for defining time in the hospital or inpatient setting. This time includes any time that is spent on the patient, including at bedside or on the unit while reviewing a patient’s charts and communicating with other professionals. Any time that is not on the unit, though it may have been spent on the patient, is not included while calculating time.

CMS offers further clarification for time-based coding that is not specified by the CPT® guidelines already provided. In the office/outpatient setting, all time spent coordinating care or on counseling must be provided while in the patient’s presence. In person time only includes time spent in direct contact with the physician. Counseling provided by any other staff member isn’t to be included as “the in-person” time between the physician and the patient.

After the patient is no longer present in the office, or the physician is no longer on the same floor as his patient or is providing care for another patient, any time spent counseling the patient or coordinating the patient’s care is not considered as the level of service to report is determined.

CMS further clarifies that when reporting E/M services for time spent in a teaching setting, only that time spent by the teaching physician can be reported as time. In the absence of the teaching physician, any time spent by a resident cannot be included in total time.

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