Code E&M Service by Content, not Duration

Medicare policy dictates that the duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for noninpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care.

The physician must have provided all the services necessary to meet the current procedural terminology (CPT) description of the level of service billed. A physician may submit a claim for CPT code 99499, unlisted evaluation and management service, with a detailed report stating why the visit was medically necessary and describing what service(s) was performed. Medicare has the discretion to place a reimbursement value on the service when it does not meet the terms of a CPT description. CPT modifier -52 (reduced services) must not be used with an E&M service. Medicare does not recognize modifier -52 for this purpose.

When counseling and/or coordination of care accounts for more than 50 percent the face-to-face physician/patient encounter of the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E&M code, the physician must complete two out of the three criteria applicable to the type or level of service provided for established patients, and three out of three criteria for new patients. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and provide a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

Example: A cancer patient has had all preliminary studies completed, and a medical decision has been made to implement chemotherapy. At an office visit, the physician discussed the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

Note: Physicians should contact commercial payers for their policies relating to E&M services.

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