Medical Decision Making vs. Total Time | Coding & Billing | MD&D #31

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Life and Finances, in Medicine.

You finish seeing a patient in the office. You document your encounter and now comes the question: which E/M code should I use?

Remember the good old SOAP note we learned in medical school? Well, it is very much alive and current, for a multitude of reasons. Today, we will address its importance in the selection of the E/M code.

For office visits and consultations, there are two ways to determine the appropriate E/M code to use: Medical Decision Making, (MDM), or the Total Time spent taking care of the patient during the encounter.

You don’t have to use both. But you must select a level of service based on either method. In this selection process the most important part is your note documentation. Either option is the right one, as long as the documentation supports it. Let’s address each option:

 Option 1: Code Based on Medical Decision Making (MDM)

MDM looks at the complexity of the decisions you made to provide care for your patient. As we discussed in the previous article, MDM has three components:

1.      The number and complexity of problems addressed

2.     The amount and complexity of data reviewed and analyzed

3.  The risk of complications, morbidity, or mortality associated with patient management

You don’t need to fulfill all three components. You only need two out of these three to reach a particular MDM level.

As you can tell time has nothing to do with this option. You can spend 40 minutes with a diabetic patient addressing a problem and still end up with a lower E/M level if you choose MDM to document a lower-level code.  

The opposite is also true. You could spend relatively little time with another diabetic patient addressing a problem and have moderate or high MDM if the problems, data, and management decisions in your documentation support it.

I practical terms you must remember that spending a long time with a patient does not automatically mean that the MDM itself was complex.

 Option 2: Code Based on Total Time

The second option is to select the E/M level based on the total time you spent taking care of the patient on the date of the encounter. Now, here is an important point a lot of people forget:  Total time does not mean only face-to-face time with the patient.

Qualifying time includes what you did before, during, and after the actual visit to care for the patient. This work must occur on the same date of service, and it must be related to that patient's care.

For example:

That changes the way many of us should think about time-based coding. A visit that qualifies for 30 minutes of Total Time does not necessarily mean that you spent 30 minutes physically in the room with the patient. It means that your total qualifying work for that patient on that date reached that threshold.

A few of the things that do not qualify:

·      Clinical Staff time: Time spent by nurses or medical assistants with the patient.

·      Regular office/clinical workflow: Registering the patient, rooming or taking vital signs.

·      Separate procedures: A procedure performed during the same visit (a biopsy for example) is billed separately. The time spent during the procedure does not count in the total time for E/M.

The table above, summarizes the Total Time thresholds to qualify for a specific type of encounter, both for new and established patients. Use it regularly, it is very helpful. Let me explain what thresholds mean: Under current CPT terminology, the times associated with E/M codes function as minimum thresholds. In other words, a specific threshold must be met or exceeded for you to use that specific CPT code.

So, Which One Should You Use MDM or Total Time?

Think of MDM and time as two different roads leading you to the same destination. They can both produce the same E/M level if your note is well documented, but in the end, you must choose the road that best represents your efforts. Remember:

MDM measures the complexity of the decisions you made.

Total Time measures the period you spent working for that patient on that date.

Now, there are also ways in which you can stop in the middle of one road and get to the same destination. Let me explain: (Please use the table above to better understand):

Example 1: MDM Produces the Higher Code

Imagine you see a new patient with several problems requiring moderate MDM. You reviewed the history, labs, images and other results. You considered different diagnoses, and developed a management plan that clearly supports moderate MDM. That is a level 4 encounter, or 99204 for this new patient.

But at the same time, suppose you spent only 35 minutes trying to help this patient. If you choose the code strictly based on time, 35 minutes would support a low level 3 encounter, or 99203 for this new patient.

In this situation, MDM may better represent the complexity of the encounter.

Example 2: Time Produces the Higher Code

Now, consider a different scenario. An established patient comes to your office with a relatively straightforward problem. The MDM supports a straightforward level 2 encounter, 99212 for an established patient.

But the patient spent quite a bit of time asking questions. You spent considerable time discussing options, counseling the patient, reviewing previous records, coordinating care, and completing documentation. Let’s assume you spent 25 minutes in this process. That amount of time a supports a low level, level 3 encounter, 99213 for this established patient. Not a straightforward level 2 encounter.

In this case, time may better represent the work you performed.

Example 3: Addressing Stable, Chronic Conditions

Another scenario. An established patient comes back to your office for follow-up on diabetes, hypertension, and chronic kidney disease. These are complicated chronic diseases, but they all seem stable in this hypothetical patient.

You address all these conditions and manage the medications. That supports moderate MDM, or a level 4 encounter, 99214.

But you only spent 29 minutes in the care of this patient. That timeframe supports a low level, level 3 encounter, 99213.

If you believe MDM better represents the work you performed, you may choose MDM over Total Time. And vice versa. As you can tell, the same encounter can produce different potential levels of service depending on the extent of work you performed, documentation, and the method to code that you chose. That is exactly why it is important to understand both.

Practical points to remember

·      You cannot combine MDM and time. You can’t partially qualify for one level through MDM and then add time to up-code into the next level. Each method is independent. 

·      Do not up-code just because one method will provide a higher level than the other. Use the code that better reflects your work and documentation.

·      The time threshold matters only when Total Time is the method you used to select the code

·      If you decide to use Total Time for a specific encounter, you just need to reach the minimum time threshold for that level of encounter. For example, at least 40 minutes for an established patient in a level 5 encounter (see table above).

·      The old “More Than 50% of the encounter counseling” rule is gone. I still hear people quoting this to justify their selection of an encounter level. But that rule was cancelled in 2021. Total Time may be used whether or not counseling or even care coordination were part of the encounter.

·      If you use total time, AMA specifies that you do not need to document the time you spent on each individual task involved in caring for the patient on the encounter day. You just need to document the total time associated with the visit. You can document, for example:

“Total time spent on the date of the encounter: 35 minutes, including review of records, evaluation of the patient, analyzing lab results and imaging, counseling, care coordination, and documentation.”

·      Regardless of the method you select, your history and physical are still very important, not only for clinical purposes but for appropriate documentation of the patient’s condition and management supporting your coding selection.

·      Choosing MDM as your method for one patient encounter, does not mean you cannot use Total Time as your method for another encounter on the same patient.

·      The choice between MDM and Total Time works for office encounters and consultations. Not for ER visits. Due to the nature and variety of the encounters ER visits that do not qualify as critical care are only coded by MDM. Not by Total Time.

·      On the other hand, in Critical Care coding is based on time only. Not on MDM. Critical Care has its own requirements regarding what qualifies as critical care and what time can be counted.

E/M coding does not have to be a headache. Once you are familiar with the nuances of each method, your election becomes automatic. Understanding both methods allows you to document more accurately, code more confidently, and make sure that the work you perform is appropriately represented.

1. MDM and time are two independent ways for you to choose the E/M code for your patient encounter.

2. The two methods may produce the same or different code levels.

3. Your election should accurately represent the work you performed and must be appropriately documented.

“The secret of the care of the patient is in caring for the patient.”
Francis W. Peabody

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