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Billing time-based codes in the hospital

Time is on your side.

March 2016

IN THE JANUARY ISSUE, my coding column discussed the new codes for advance care planning services (99497-99498)—which, like several other code sets in the current procedural terminology (CPT) manual, are reported based on time. Other examples that will be very familiar to most hospitalists include critical care and prolonged services.

At press time, there were some questions surfacing about whether these codes will be paid in the inpatient setting. (Those questions have since been resolved, and advance care planning codes billed from hospitals are being paid.) In the meantime, let me address several questions I’ve received related to advance care planning codes since my last column was published.

Accurately documenting time for time-based codes can reap both financial and compliance rewards.

Here’s one example: “If I spend only 10 minutes in advance care planning, I can still bill 99497, right?” Actually, you can’t. Let’s look at why.

Passing the midpoint

If you use any time-based codes in your day-to-day work, you must understand the specific criteria you need to meet for each code set.

The CPT manual offers an introduction section at the front of the book. It contains valuable information about how to use the CPT manual as well as definitions of and guidelines for various aspects of coding and code-related criteria.

One of those topics is time, and it’s a fascinating read if you can’t get your hands on the latest bestseller! For those of you who don’t plan on cozying up with the manual, here’s one key fact about CPT guidance on time, included in that introduction: “a unit of time is attained when the mid-point is passed.”

Let’s take, for example, prolonged services with direct patient contact (CPT codes 9935499355). These codes contain a descriptor that states “first hour” (referring to the first hour of care beyond the usual E/M service time threshold). In the CPT manual, an accompanying table indicates that you can’t separately report prolonged services of less than 30 minutes. Why? Because you haven’t surpassed the midpoint of that particular time descriptor.

In other words, you may bill (and expect to get paid for) the first hour of prolonged services code only if you report spending 31 minutes or more on that service. For a CPT with a second “add-on” code pairing for “each additional hour” (such as 99355), you can report that second CPT code only after spending at least 91 minutes providing that service.

Critical care

Let’s go back to advance care planning codes. These codes, which are new for 2016, include CPT code 99497: advance care planning services, first 30 minutes.

Using the midpoint defined in CPT, you would not be able to report this code until you’ve spent more than 15 minutes on advance care planning services. Likewise, for the advance care planning add-on code (99498, each additional 30 minutes), you shouldn’t bill and you won’t be paid unless you spend more than 45 minutes.

The CPT manual, of course, is put out by the American Medical Association. In general, the Centers for Medicare and Medicaid Services (CMS) follow the same midpoint criteria as CPT.

But if you’re looking for a direct CMS reference, you may be looking a long time. The CMS typically includes guidance related to time-based services only in various Web-based manuals.

Take, for example, the Internet-Only Manual 100-4, chapter 12, section 30.5, which provides information on administering chemotherapy. Sub-section E makes a reference to reporting the “each additional hour” infusion code only if the infusion continues passed the 30-minute point: “The physician may report the infusion code for ‘each additional hour’ only if the infusion interval is greater than 30 minutes beyond the 1 hour increment.”

And in section 30.6.12, sections F and G, you’ll find information about critical care services. These codes are a bit different. As you know, 99291 is for critical care, first 30-74 minutes, while 99292 is for critical care, each additional 30 minutes.

In terms of 99291, the code itself spells out the minimum amount of time you must spend in that service to be able to bill, so the idea of any midpoint does not apply. You cannot separately report critical care services that are less than 30 minutes in total duration for a date of service. Instead, you would have to bill a different E/M service.

Document, document, document

One last remark: Accurately documenting time for time-based code sets can reap both financial and compliance rewards. Third-party payers seem to review time-based codes more frequently.

Providing clear and concise documentation of time may reduce unwanted audit scrutiny, while paving the way for prompt adjudication of claims. If you understand and appropriately use these codes, time will definitely be on your side.

Sue A. LewisSue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.


Published in the March 2016 issue of Today’s Hospitalist