Background
When billing for healthcare services, providers can choose between two primary methods: Medical Decision Making (MDM) or Time. Here’s a brief explanation of each:
MDM (Medical Decision Making) Rules Summary
- Complexity Levels: MDM is categorized into levels based on complexity – straightforward, low, moderate, and high complexity.
- Three Key Components:
- Diagnosis & Management Options: Evaluating the number and complexity of problems addressed during the encounter.
- Data Review & Analysis: Considering the amount and complexity of data to be reviewed and analyzed, including records, tests, and other information.
- Risk of Complications & Morbidity/Mortality: Assessing the risk associated with patient management decisions, including potential complications and the patient’s overall health status.
- Documentation: Proper documentation is essential for coding and billing purposes, reflecting the MDM level.
- Coding and Billing: The level of MDM directly influences the coding of a service for billing, with higher complexity usually leading to higher reimbursement rates.
- Updates and Changes: Periodic updates to MDM guidelines can occur, so staying current with coding standards and guidelines is important for healthcare providers.
Time-Based Billing Summary
- Definition: Billing based on the amount of time a provider spends with a patient, rather than the complexity of the service.
- Applicability: Particularly relevant for services where time is a critical factor, like counseling, psychotherapy, or lengthy discussions about treatment options.
- Documentation Requirements: Accurate documentation of time spent with the patient is crucial. This includes start and end times or total time spent.
- Thresholds: Certain thresholds of time must be met or exceeded to bill for specific time increments.
- Different Types of Time: Considers face-to-face time for outpatient services, and both face-to-face and non-face-to-face time for inpatient services.
- Billing Codes: Different codes are used for different time increments, and providers must use the appropriate codes that correspond to the actual time spent.
- Patient Interaction: Time-based billing is only for time directly spent on patient care, not on indirect activities like reviewing results without the patient.
- Telehealth Considerations: With the rise of telehealth, time-based billing also applies to virtual consultations, with specific guidelines for documenting and coding these services.
Common E&M Codes with Time and MDM Criteria – Updated for 2024
| CPT Code | Time | MDM Criteria |
|---|---|---|
| 99213 | 20 | – Low complexity
|
| 99214 | 30 | – Moderate complexity
|
| 99215 | 40 | – High complexity
|
| 99205 | 60 | – High complexity
|
| 99204 | 45 | – Moderate to high complexity
|
| 99203 | 30 | – Low to moderate complexity
|