APMA News - November/December 2021 - 42

Coding
By Luke Hunter, DPM, and Michael J. King, DPM
Time-Based Coding and Evaluation &
Management Procedures
Billing and coding experts often say, " The Evaluation &
Management (E/M) is included in the procedure, " when a
more accurate statement would be, " A certain amount of time
spent evaluating the condition and deciding to do a procedure
is included in the procedure. " What does this statement
mean? If you spend enough time evaluating the pathology-
evaluation time that goes beyond what is allotted-and
document this additional time, you may be able to justify
submitting an E/M service with a 25 Modifier1
in addition to
the procedure if that E/M is significant and separately
identifiable from the procedure.
Chapter I, Section D of the National Correct Coding
Initiative Policy Manual for Medicare Services1
states, " An
E&M service is separately reportable on the same date of
service as a procedure under limited circumstances. " An E/M
is significant and separately identifiable from a procedure if
there is no overlap in the work related to the E/M and the
work related to the procedure. Chapter I, Section D of the
policy manual2
states
that
a significant and separately
identifiable E/M exists if it does not " include any work
inherent in the procedure, supervision of others performing
the procedure, or time for interpreting the result of the
procedure. " The manual also indicates that " [t]he decision to
perform a minor surgical procedure is included in the
payment for the minor surgical procedure, and shall not be
reported separately as an E&M service. " 2
There are
certain
situations
Beginning with CPT 20211
in which an office/other
outpatient E/M level may be selected based on time. Let's
review:
, an office/other outpatient E/M
level may be selected based on one of the following:
1. The level of the MDM as defined for each service
OR
2. The total time spent by the provider performing the E/M
service on the date of the encounter.
These 2021 CPT changes were a major change and are
positive for podiatry. Let's examine the second option further,
as there are some nuances that need to be explored.
While not the case for CPT 99211, total time alone may
be used to select the appropriate level of all other office or
other outpatient E/M services CPT codes (CPT 99202-99205
and CPT 99212-99215). Total time may be used to select
the office or other outpatient E/M level whether or not
counseling and/or coordination of care dominates the service.
42 APMA News November/December 2021
At the time of this writing, that is not the case for nonoffice/other
outpatient E/M services where time may only
be used for selecting the level when counseling and/or
coordination of care dominates the service. (Exception:
Time
is not
considered
when
choosing
Emergency
Department E/M levels.)
What can be included in the calculation of time spent?
While not an all-inclusive list, CPT does provide a list of
examples:
* preparing to see the patient (e.g., review of tests)
* obtaining and/or reviewing separately obtained history
* performing a medically appropriate examination and/or
evaluation
* counseling and educating the patient/family/caregivers
* ordering medications, tests, or procedures
* referring and communicating with other health-care professionals
(when not separately reported)
* documenting clinical information in the electronic or other
health record
* independently interpreting results (not separately
reported) and communicating results to the patient/
family/caregiver
* care coordination (not separately reported)
Do not count time spent on the following:
* travel
* teaching that is general and not limited to discussion required
for management of a specific patient
* performance of other services that are reported separately
While it may be clear what activities can be counted as time
spent, let's explore what can't be counted toward total time.
Performance of Other Services
Simply put, time devoted to another service cannot be
used to determine E/M level. Whether it's an X-ray or a
matrixectomy, there is a component of time included in
the performance of those procedures. Knowing how to
look up the time components included in a procedure may
help in contesting inappropriate modifier 251
denials and
prevent an entity from claiming either false billing or
fraudulent overbilling.
For example, if you take three X-ray views of a patient's foot
and submit CPT 73630, this code represents taking the
X-rays and the interpretation. You cannot use the time spent
APMA News - November/December 2021

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