Take the Time to Get Time-Based Billing Right

By Erica E. Remer, MD, CCDS

I am currently performing a fraud assessment, and since I can’t go back and educate the provider in question, I am going to share my insights with you. Since Jan. 1, 2023, practically speaking, all evaluation and management (E&M) service coding is based on medical decision-making or time. And some providers are not documenting time appropriately.

• It’s no longer only face-to-face (F2F) time or time spent on the floor or unit that counts. It is the total time devoted to the patient, which includes some component of F2F time on the day of the encounter.

  Consider the following:

  • The face-to-face time may be delivered by another qualified healthcare professional, as opposed to the ultimately responsible billing individual, if the time is split/shared or incident-to.

  • Counseling and coordination of care not separately billed for may be counted, but there is no longer a threshold of greater than 50 percent of the time. That should be removed from any attestations.

• Time need not be continuous, but you can only count time solely devoted to the patient for that given time interval. Maybe it is your practice to review labs in the morning before you start your rounds or your office hours. Then, a few hours later, you see the patient and do a history and physical. You order some tests (the time clicking in the electronic medical record counts), which you discuss afterwards with the patient because it informs your shared decision-making. You prepare discharge instructions. At the end of the day, you spend quality time with the electronic health record (EHR) documenting the encounter. All of that time can be added up and claimed. Remember:

  • It may not be practical to use a time-tracking app, but you should be able to guesstimate accurately. Be truthful. Time spent on separately billed activities should be carved out. You can’t double-dip.

  • If two individuals see the same patient at the same time, providing the same service (e.g., rounding together), only one of them can claim any given moment in time. You can’t double-dip.

• Don’t give a range of time, e.g., 30-74 minutes. Some time-based services, like critical care, can be additive. What number would you use to add? How can you tell if prolonged services add-on is appropriate if a range is given?

• Don’t document “approximately 35 minutes.” Does that mean “34 minutes,” which is under the threshold, or “36 minutes,” which crosses it?

• Similarly, don’t document “greater than 35 minutes.”

• Detail some activities you are including in your time-based billing. If you have a standard macro, I strongly recommend editing it to reflect the services you provided today, with this patient.

• Personal chit-chat, although it can take time, cannot be counted in time-based billing. There are specific activities that are permissible (see https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf) to be counted.

Remember that an auditor is looking at documentation over time and over multiple patients. If you only use macros or templates or copying and pasting the reviewer will notice. The auditor will be trying to get a feel of what you are doing over the course of the day. Did you really perform that physical exam if it is identical from patient to patient, and never changes over time?

• If your documentation has a field to put the date and time seen, try to be accurate. Unless you are office-based and never run late or have issues that throw your schedule off, it looks suspicious to run exactly on the hour or half-hour for every patient, every day. In the hospital? You never used the restroom or grabbed a snack or answered a phone call or got waylaid in the hall by a nurse?

• If you have fields where you put start and stop times for your F2F time, label them as such. As noted, there are a lot of other activities that may be counted in time-based billing, and it is perfectly reasonable that you wouldn’t be documenting to account for those administrative and not-in-the-presence-of-the-patient times in the progress or office note. But it looks funny if it says at the top of the note, “Time: 4:00-4:30 p.m.” and at the bottom of the note, it just says “35 minutes were spent.” This is an internal inconsistency.

• It looks suspicious if you run back-to-back 30-minute intervals all day long, claiming 35 minutes for each, and completing the documentation before you see the next patient. It looks really bad if you document that you saw a patient when the nurse records they were sleeping. It is impossible to see patients in the drive time between facilities. You can’t prospectively document an encounter.

• In this day and age, assume that investigators will be able to ascertain where you physically were. Don’t lie and say you were at the hospital when you were in the grocery store or in another state.

• Remember that electronic records have an audit trail. You may (truthfully) assert that you saw a patient at 10 a.m. while documenting the encounter at 1 p.m., but you can’t fix it, so the computer says you typed it at 10 a.m.

In order for an encounter to be billable, it needs to meet medical necessity. If the medical decision-making is moderate, but the patient requires more time than is typical for a 99232 (subsequent hospital care) because they have a lot of questions, a 99233 can be justified on the basis of time. However, if a patient is completely stable and has no new problem, and there no studies to analyze or changes in medication or plan of care, and they are to be discharged the next day (i.e., = 99231), you are hard-pressed to claim the highest level of service. Why did it take you so much time?

Here are my recommendations:

• Only put your billing-by-time attestation on the encounters for which you are billing by time. It is confusing for your selected level of service to be one level, but the time attestation would support a different level. It calls into question the veracity of the time attestation on all patients.

• Be consistent. If you have start/stop times documented, but are claiming the encounter took more time, explain the discrepancy – e.g., “38 minutes spent, which includes 20 minutes face-to-face, as noted above, review of labs, ordering tests and neuro consult, and documenting in EHR.”

• Don’t let your times add up to more hours than it is humanly possible to work in a day.

• Tell the truth. Do good-faith guesstimates. Don’t always use the same number. Feel free to not use round numbers, like using 31 as opposed to 30.

• You won’t get in trouble for the occasional 35-minute encounter being claimed as 38 minutes. You will get in trouble if you claim one hour when you only spent 17 minutes.

Take the time to get time-based billing right. If you provided the service, you want to be appropriately compensated.