Coding Q&A: Coding for time spent with hospital patients; medication reconciliation

Q1: I’m trying to come up with a statement I can use to document time I spend on hospital patients. Can I say, “I spent ___[X]____ minutes on the floor examining ___[Y]____, talking to the family, and placing orders”. Can I say, “MDM time,” which the ER physicians say in their notes?

A1: You are on the right track, but I’d suggest you say something a little different, now and in 2021 as well.

Although the definition of hospital time for coding purposes is described as 'floor time' that’s not really the part that needs to be spelled out. Like the 'counseling' time in the office, for inpatient time you need to document that over half of the total time was spent in either 'coordination of care' or ‘counseling’ and document what the total (floor) time was.

At minimum you need to say, “Spent over 1/2 of XX minutes coordinating care with A and B and C regarding X, Y and Z”. It's not a good practice to generically say, “coordinating with the rest of the team”, or “talking to the family, placing orders”. Instead, say “working with the social worker to arrange discharge” or “speaking with Mom and daughter about plans to do this or that ....”. That's the right way to do it. 

Medicare, in particular, doesn’t care for generic time comments—these need to be personalized to the patient and the circumstances, and support medical necessity. 

And the “that's what the ER docs do” comment is a bit baffling—ER professional codes have never been able to be coded by time. No guidance ever suggested that the 'time' be linked to that spent on decision-making. That concept seems to be a mix of several guidelines that don’t take you there. Only during the pandemic were ER docs, like everyone else, allowed to code by MDM alone, and that was for telehealth visits only.

Remember that although the outpatient guidelines change in 2021 to eliminate the need for the ‘counseling or coordination of care’ aspects of coding by time, the inpatient codes are not impacted by this. The earliest that that could happen would be 2022, and that’s unlikely.

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Q2: I have a question about medication reconciliation. Are there opportunities to bill for Med rec outside of the Transitional Care management codes 99495 and 99496?

A2: The TCM codes you mention seem to be the only fee-for-service CPT codes that specifically involve Medication reconciliation. And that is just one requirement of those codes. There is the quality measure code for 1111F for MIPS reporting that covers medication reconciliation performed within 30 days of a hospital discharge.

But when you ask about 'other opportunities' this may well have a place in the new definitions of time-based office visit codes 99202 – 99215 that will be fully in place come January 2021.

In 2021, with the revised definition of time that includes some amount of pre- and post-visit activities, this could easily fit under the 'preparing to see the patient' or documenting clinical information in the EHR, with the Med recc time contributing to the overall time method of code selection.

Even now in 2020, were you to involve the patient in the process, this may in some circumstances count towards overall counseling time.

_{About the Author}

_{Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at billdacey@msn.com.​}