433Billing on Time
It is the last appointment of the day, and you are tired. The patient encounter starts
off pleasant enough, but then the patient reaches into a book bag and proceeds to
pull out three pages of meticulously handwritten questions. You covertly text your
spouse you will be late for dinner. You spend a total of 45 min with the patient and
answer myriad questions. You quickly realize you didn’t actually take any history
and don’t know what to document. All is not lost; this is the perfect patient to bill on
time. With the last of your strength, you log in to your computer and type:
I spent a total of 45 min of face-to-face time with the patient discussing his
myriad questions on the risks and benefits of penile implant surgery with > 50% in
direct patient counseling.
Boom, you can bill E5 since this was not a new patient, and you consulted
Table 23.1. The above sentence is all you need, nothing else whatsoever.
You should bill on time when counseling or coordination of care dominated
(>50%) the MD/patient encounter. In this case, time can be considered the key or
controlling factor to qualify for particular level of service. The total length of time
as well as the counseling or activities to coordinate care should be documented.
Remember that office or other outpatient activities need to be your face-to-face time
(not the resident or your PA or the med student). Hospital or nursing facility is floor
time and DOES NOT need to be face-to-face when billing on time. Review the time
thresholds again (Tables 23.1 and 23.2), and realize that timed billing sets itself up
very well for E4 and E5 visits. The time requirements for new appointments are
pretty steep. There is controversy over time increments (see next section on ambigu-
ity); some groups state that a unit of time is attained when the midpoint has passed.
When codes are sequential, some state you should pick that which is closer. Others
state you need to spend all of the threshold times face-to-face with the patient.
Billing tip – If you look at films or patient records in the midst of your clinic day,
make a concerted effort to do it with the patient present. A simple explanation like
“With your permission, before we begin our appointment, I would like to review
your records and films to make sure I totally understand your history.” This accom-
plishes two things: it lets the patient actually see how much time you are spending
on their case (as well as see their own films – they love that), and it sets the stage to
bill on maximized face-to-face time.
Putting It All Together and Knowing Your Auditors
So now you know how to bill each individual section. How do you determine the
bill to submit? Quite simple really, you may only bill the lowest of the three pillars.
Thus, if you bill a level 5 visit for a new patient, history, PE, and MDM, all need to
reach level 5. If your history section only qualifies for level 3 and your PE and
MDM are level 5, you may only bill level 3. Another important point is to think
about who is potentially reviewing your notes. It is not physicians, so they will not
understand any unmentioned nuances. I always picture some kid out of high school
23 Evaluation and Management Documentation, Billing, and Coding