Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.
For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.
Counseling, Coordination of Care
Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.1 Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.
Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.
When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.
Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.2 “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”
A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.
Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:
- The patient is unable or clinically incompetent to participate in discussions;
- The time is spent on the unit/floor with the 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; and
- The conversation bears directly on the management of the patient.4
The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.
It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.