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Coding Corner

Advice on how to bill Medicare based on time spent counseling patients, and how to make verbal orders stick

By Brian Whitman

From the February ACP Hospitalist, copyright © 2008 by the American College of Physicians

Q: Should I bill according to the time it takes me to see a patient?

A: In most cases, physicians should select the level of an evaluation and management (E/M) code based on the documentation of the history, exam and medical decision making. However, in some cases E/M codes can be determined according to time spent with the patient. In order to select a code level based on time, the physician must spend at least 50% of the visit counseling or coordinating care for the patient. The level is based on the typical times for CPT codes, which follow the code in the CPT book and say "physicians typically spend xx minutes."

In cases where physicians spend most of their time counseling, the documentation of history, exam and medical decision making does not drive the selection of the code.

In cases where physicians spend most of their time counseling, the documentation of history, exam and medical decision making does not drive the selection of the code. The physician still should be documenting for the purposes of patient care and should include in the record the total time spent with the patient and the time spent on counseling or coordination of care. This documentation should also include a chief complaint and a brief explanation of why the counseling or coordination of care was needed.

Inpatient physicians should base their coding on both the time spent directly with a patient and time spent in the unit on the issue. Time spent counseling the patient's family when they have legal authority to make medical decisions could be included in the time calculation. These conversations would not have to take place in the patient's room, but would have to take place somewhere in the unit where the patient is staying.

Physicians could bill the following level of subsequent hospital visits based on time:

• 15 minutes: 99231
• 25 minutes: 99232
• 35 minutes: 99233

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Q: I heard that Medicare recently made changes to its rules on verbal orders. What do I need to know about them?

A: Hospitals must meet the requirements under "Medicare Conditions of Participation" in order to bill for Medicare patients. In 2007, some changes were made to these conditions relating to the use of verbal orders in the hospital setting. The first change addressed the issue of who may sign a verbal order. In the past, the physician who issued the order was required to authenticate or sign the order. With this new rule, any physician who is responsible for the care of the patient and is eligible to make orders in the hospital may authenticate a verbal order made by another physician. A physician is not required to authenticate another physician's order.

The second change addresses how long after issuance a verbal order would have to be signed. The new rule requires that all orders must be authenticated within 48 hours. Some states require orders to be authenticated in less than this time. The rule also requires that the time—not just the date—must be documented in all medical record entries in the hospital chart. This requirement is not only for authentication of verbal orders but for all elements of the inpatient medical record.

The Conditions of Participation for hospitals repeatedly stress that verbal orders should be a rare occurrence in the hospital setting because of the potential patient safety issues caused by a misheard verbal order. This rule intends to minimize the impact of these problems.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington, D.C. office. His column will appear every other month. E-mail coding questions or issues to acphospitalist@acponline.org.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated