Since January 2021, healthcare providers have had the flexibility to select the level of evaluation and management (E/M) service based on either the complexity of medical decision-making (MDM) or the total time spent on the date of the encounter. This flexibility allows providers to choose the method that best reflects the care provided during a patient visit. Importantly, providers are not required to use the same method for every patient—each encounter can be assessed individually, depending on which approach is most beneficial to the provider.
Evaluating Time-Based E/M Levels: Pros and Cons
Advantages of Using Time as the Primary Factor
One of the main benefits of using time to determine E/M service levels is its measurability. Providers who consistently document the time spent caring for a patient are credited for all time, not just the time spent during the in-person encounter. This allows providers to account for additional tasks performed outside of the patient’s presence, such as reviewing records, discussing care plans with other providers, or preparing documents.
Time-based reporting can also make longer visits eligible for prolonged service add-on codes, such as:
- CPT code +99417 for outpatient services.
- CPT code +99418 for inpatient or observation services.
These codes apply to any time spent beyond the required duration for the primary service level, billed in 15-minute increments.
Finally, in some cases, counting time can be simpler than evaluating all the elements of MDM, especially when determining the complexity of the medical decision-making process.
Drawbacks of Time-Based Reporting
Despite its advantages, time-based reporting has limitations. For example, the total time recorded cannot exceed the time spent directly seeing the patient on that date. Some insurance payers place strict limits on time-based billing, which can lead to the identification of “impossible days”—instances where the reported time appears suspiciously high.
Additionally, time can only be counted on the specific date of service. Providers who complete tasks before or after the patient encounter, such as reviewing lab results or coordinating care, cannot count that time. This limitation can make it challenging for providers with busy schedules to accurately document all the time spent on a patient’s care, especially if the work is spread out over multiple time blocks during the day.
The Complexity of MDM-Based E/M Levels: Pros and Cons
Advantages of Using MDM for E/M Level Selection
MDM-based service level determination is advantageous for certain patient scenarios. For example, patients with complex conditions that require a large number of tests or decision-making steps may benefit from an MDM-focused approach. This method is particularly beneficial for specialists like surgeons, who often order numerous tests that require independent interpretation, or for providers who manage complex medication regimens.
Challenges with MDM
However, MDM-based E/M levels come with challenges. One of the primary concerns is medical necessity. Auditors may question whether the ordering of numerous tests was truly necessary or whether an independent interpretation was justified in a given case. Providers must also be cautious to avoid duplicating services—for example, interpreting a test as part of the MDM process while separately billing it under a distinct CPT code, such as an imaging service.
Furthermore, the MDM table can be more complex and subjective, with multiple columns and criteria that require careful interpretation. Assessing the level of risk (low, moderate, or high) can be particularly subjective, and distinguishing between a severely exacerbated condition and a more stable one may involve some degree of judgment.
Conclusion
Both time-based and MDM-based E/M service level determination methods offer distinct benefits and challenges. Providers must carefully assess their practice needs, patient conditions, and documentation practices to determine which method best reflects the care provided during a patient encounter. In all cases, accurate and thorough documentation is essential for ensuring a clear and justifiable selection of the E/M service level.
Frequently Asked Questions (FAQs)
Q: Can I switch between time-based and MDM-based reporting for different patient encounters?
A: Yes, providers can choose either method for each patient encounter. The decision does not need to be consistent across all patients, as it can depend on which approach is most advantageous for the specific visit.
Q: Can I count time spent on tasks like reviewing patient records or consulting with other providers?
A: Yes, time spent on tasks like reviewing patient records or consulting with other providers can be counted, but it must be documented and completed on the same date of service as the patient encounter.
Q: What is the difference between MDM and time-based reporting?
A: MDM focuses on the complexity of medical decision-making, such as the number and type of tests ordered or the level of risk involved. Time-based reporting, on the other hand, counts all time spent on patient care, including time spent outside of the actual patient encounter.
Q: Are there limits on time-based billing?
A: Yes, many payers set limits on time-based billing to prevent excessive claims. Additionally, time-based reporting can only count the time spent directly on the patient’s care on the date of service.
Q: What should I do if I’m unsure which method to use for a patient encounter?
A: Consider the complexity of the patient’s condition and the amount of time you spend on their care. Document all relevant activities thoroughly and select the method that most accurately reflects the care provided.
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