Practice Economics

Bill by Time Spent on Case


In my recent columns, I addressed documentation guidelines with respect to the three key components: history, exam, and medical decision-making. However, time is considered the fourth key component.

Time-based billing places significant emphasis on the duration of the hospitalist-patient encounter more so than the detail or quality of the documentation. This month, I’ll focus on the guidelines for reporting inpatient hospital services based on time.

Code This Case

A newly diagnosed diabetic requires extensive counseling regarding lifestyle changes, medication regime, the disease process as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient (15 minutes) and asks the resident to assist him with the remaining counseling efforts and coordination of care (25 minutes). Each document their portion of the service? What visit level can the hospitalist report?

The Solution

The billing provider’s time counts. In this instance the attending physician accumulated 15 minutes of time, equivalent to 99231 (subsequent hospital care). However, if the physician obtained and documented history or exam, in addition to the medical decision-making and counseling portion, a higher visit level may be reported if appropriate.

Counseling, Coordination

Hospitalists try to make their rounds as efficient as possible while still upholding a high standard of care. It is not unusual for a patient encounter to vary from the norm of updating the history, performing the necessary exam, and implementing the plan.

In fact, hospitalists often counsel patients with newly diagnosed conditions or when treatment options seem extensive and complicated. Based on these circumstances, physicians can document only a brief history and exam or none at all, since the bulk of the encounter focuses on medical decision-making, counseling, and coordination of care. Despite the minimal documentation compared with other physician services, it still is possible to report something more than the lowest service level (e.g., subsequent hospital care, 99231).

To use time as the determining factor for the visit level, more than 50% of the total visit time must involve counseling/coordination of care. The total visit time encompasses both the face-to-face time spent with the patient at the bedside and the additional time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers. Physicians providing care in academic settings cannot contribute teaching time toward the total visit time. Further, only the attending physician’s time counts.

Code of the Month

Counseling/Coordination of Care

Total visit times are used for selecting the visit level only when the majority of the patient encounter involves counseling and/or coordination of care. It is not to be used for determining the visit level when counseling/coordination of care is minimal or absent from the patient encounter. Inpatient visit times reflect the counseling/coordination of care time spent on the hospital unit/floor by the billing provider.

Total Visit Times (Minutes)

Initial Hospital Care

99221 30

99222 50

99223 70

Subsequent Hospital Care

99231 15

99232 25

99233 35

Inpatient Consultations

99251 20

99252 40

99253 55

99254 80

99255 110


Hospitalists must document events during the patient encounter. There may be little or no history and an exam and counseling may dominate the entire visit.

Physicians must document both the counseling/coordination of care time and total visit time. The format may vary: “Total visit time = 25 minutes; more than 50% spent counseling/coordinating care,” or “20 of 25 minutes spent counseling/coordinating care.” Any given payer may prefer one documentation style over another. It always is best to query payers and review their documentation standards to determine the local preference.

In addition to the time, physicians must document the medical decision-making and details of the counseling/coordination of care. For example, patients with newly diagnosed diabetes need to be educated about their condition, lifestyle, and medication requirements. Physicians should include information regarding these factors in their progress notes as necessary.

Family Discussions

As noted in my previous article on critical care services (March 2008, p. 18), family discussions can contribute toward counseling/coordination of care time when:

  • The patient is unable or clinically incompetent to participate in discussions;
  • Time is spent on the unit/floor with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; or
  • The conversation bears directly on the management of the patient.

Prolonged Care

A physician makes his rounds in the morning. He cares for a 72-year-old female with diabetes, end-stage renal disease, and hypertension. In the afternoon, he returns to find the family waiting with questions. He spends an additional 30 minutes speaking at the bedside with the patient and family. The additional afternoon effort may be captured as prolonged care if both services are documented appropriately.

Threshold Time for Prolonged Care Services click for large version

click for large version

For inpatient services, CPT defines code 99356 as the first hour of prolonged physician services requiring face-to-face patient contact beyond the usual services (reportable after the initial 30 minutes). Code 99357 is used for each additional 30 minutes of prolonged care beyond the first hour (reportable after the first 15 minutes of each additional segment). Both codes are considered add-on codes and cannot be reported alone on a claim form; a primary code must be reported. Code 99357 must be used with 99356, and 99356 must be reported with one of the following inpatient service [primary] codes: 99221-99223, 99231-99233, or 99251-99255.

Prolonged care employs the concept of threshold time. This means total face-to-face physician visit time must exceed the time requirements associated with the primary codes by 30 minutes (e.g., 99232 plus 99356 = 25 minutes plus 30 minutes = 55 total face-to-face attending visit minutes). Accordingly, the physician must document the total face-to-face time spent during each portion of care in two separate notes or in one cumulative note. Be aware that this varies from the standard reporting of counseling and/or coordination of care time in that the physician must meet the threshold face-to-face-time requirements (see Table 1, left), making prolonged care services inefficient. When two providers from the same group practice split the threshold time (e.g., physician A provided morning rounds, and physician B spoke with the family in the afternoon), only one physician can report the cumulative service. To reiterate, 99356 must be reported on the same invoice as the primary visit code (e.g., 99232). Be sure once again to query payers, because most non-Medicare insurers do not recognize these codes. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

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