November 19th, 2015
By: Codapedia Editor (Thu, Mar/12/2009)
Yes, both inpatient and outpatient consults may be coded based on time, when the conditions for using time are met.
CPT® tells us that a physician or NPP may use time to select a code when counseling "dominates" the visit. CMS confirms these rules in their Documentation Guidelines. This is what they say in the 1995 Guidelines (and the 1997 ones, as well.)
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR
COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more than 50%) of the
physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or
floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to
qualify for a particular level of E/M services.
!DG: If the physician elects to report the level of service based on counseling
and/or coordination of care, the total length of time of the encounter (face-to-face or
floor time, as appropriate) should be documented and the record should describe
the counseling and/or activities to coordinate care.
What does the clinician need to document?
- The total time of the visit
- The fact that more than 50% was spent in counseling
- A description of the nature of the discussion
For outpatient consults, it is the total, face-to-face time with the patient that is counted. For inpatient consults, the unit time is the time used to select the code. Select the code based on the total time, not the counseling time.