New Year means new guidelines! Effective January 1, 21 either medical decision making or total time may be used to support the level of service for office and other outpatient EM services. Total time is defined as “total time spent on the day of the encounter.” Don’t panic! We will get through this together.
Grab your provider and run down the simple criteria that need to be documented. So, what activities count for total time on the date of the encounter?
- Preparing to see the patient
- Review tests
- Review separately obtained history
- Performing a medically necessary examination/evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, procedures
- Referring and communicating with other healthcare professionals
- Documenting clinical information
- Independently interpreting results
- Coordinating care
These activities qualify as time where they cannot be reported separately. So be careful – if they can be reported separately don’t count the time for the EM visit; that’s known as “double dipping”. Remind your providers their documentation must reflect actual time spent, and that they must summarize each activity in the medical record and record the time spent. The time can be documented with start and stop times and/or total time in minutes. See time requirements below:
|New patient code||Total time 2021||Established patient code||Total time 2021|
|99203||30-44 minutes||99212||10-19 minutes|
|99204||45-59 minutes||99213||20-19 minutes|
|99205||60-74 minutes||99214||30-39 minutes|
I am sure we will have plenty of providers thinking “record the time” and they have done their job. That is not the case with this new guideline. Never forget, “If it isn’t documented it isn’t done.” Good luck, and feel free to reach out to me with any questions!