In a NYTimes Op-Ed piece entitled ”A Shortcut to Wasted Time“, internist Leora Horowitz bemoans the erosion of the medical record, once a means to communicate about a patient’s health, now merely an electronic repository for the minutiae of a medical encounter required for docs to get paid for the work they do. Because, as she simply puts it –

Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down.

In her editorial Horowitz tells us that she spent 40 minutes counseling an anxious patient who was neither sleeping nor eating, and how she was unable in the current payment system to bill for that visit –

Last week, I spent 40 minutes with a patient who had just placed her mother into hospice care. My patient was distraught, not sleeping, not eating. I gave her some advice, but mostly I just listened. By the end of our visit, she was feeling much better. But I wouldn’t be able to bill much for that visit based on my documentation: I didn’t review her medical or family history, conduct a review of organ systems or perform a physical exam.

What the payment system tells me to do is to cut her off after 10 minutes, listen to her heart and lungs and give her a sleeping pill. Which doctor visit would you prefer?

There are many of us who agree with Dr Horowitz about the erosion of the medical record in the era of the EMR.

But I have to disagree with her when she says she would not be able to bill much for that patient’s visit.

Because there is a simple and ethical way within the current system to easily document and get paid for medically necessary encounters such as the one Dr Horowitz describes that does not involve check off boxes, cutting and pasting, or even a physical exam.

It’s called time-based billing.

When you spend >50% of the encounter in counseling and/or coordination of care, time is the key factor in deciding the level of service. Not history, exam or medical decision making. Just time.

How do I know this?

Because I’ve been the billing compliance leader in my department for almost a decade, reviewed hundreds of my colleagues’ charts for coding accuracy, and sat through more lectures on coding than anatomy classes. If there was a GME approved fellowship in medical coding, I’d be running the damned thing.  That’s how I know.

Plus, I asked a certified medical coding expert.

Time based billing is like the WAYBAC Machine for the Medical Record

You simply document the chief complaint of the patient and the extent to which history and exam may have been done, what you talked about, including advice given and management plan, how much time you spent doing it, and indicate the diagnosis to support the medical necessity for your work.

Here’s when and how you do it, straight from the CMS Manual –

C – Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling

Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or 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 at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and 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 to implement chemotherapy. At an office visit the physician discusses 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 in order 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.

The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.

In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.

In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

How Dr Horowitz could have billed that encounter

For Dr Horowitz’s patient, there were real complaints that the patient presented with and she probably did review (and update) family history.  There were also some elements of exam – Constitutional (general appearance) and certainly Psychiatric (mood). She could document all of that, the total time she spent with the patient and the fact that more than 50% was spent (listening and) counseling, as well as a summary of the discussion points and plan.

Per CPT guidelines, the average time allotted to CPT 99215 is 40 minutes. So, I’d suggest she bill 99215 with a diagnosis of depression/anxiety, insomnia and weight loss.

Which brings up another problem

Of course, using a high level code like 99215, Dr Horowitz should be prepared for her chart to be audited, since insurers increasingly don’t want to pay for high level visits.

Which is whole ‘nuther post for whole ‘nuther day…

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WAYBAC machine image from Wikipedia