Time is money. This is especially true when it comes to coding therapeutic procedures or attended modalities correctly, particularly as they relate to time-based procedures. Your challenge is twofold: Use the coding policies required by insurance carriers and report your time correctly.
Three possible reporting standards are used: the Centers for Medicare and Medicaid Services (CMS) rules, as published in Transmittal AB-00-14; the American Medical Association guidance as published in the AMA CPT Assistant; and individual carrier policies.
Note: CMS’s usage rules are not part of the national standard code set stipulated in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Commercial carriers can follow CMS policy, AMA policy or adopt more/less restrictive coding policies of their own. When no policy is specified, a time-tested adage in billing states that if you are right with Medicare you are right with the rest of the world.
Because many commercial insurance plans currently follow Medicare Coding Guidelines or will agree that your application of those guidelines is a reasonable approach, this article focuses on the CMS standard.
What the transmittal says
The CMS transmittal dictates time reporting of 8 minutes or less:
“Several CPT codes used for therapy modalities, procedures and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers report procedure codes for services delivered on any calendar day using CPT codes and the appropriate number of units of service. For any single CPT code, providers bill a single 15 minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes. If the duration of a single modality or procedure is greater than or equal to 23 minutes to less than 38 minutes, then 2 units should be billed. Time intervals for larger numbers of units are as follows:
3 units: 38 minutes up to 53 minutes
4 units: 53 minutes up to 68 minutes
5 units: 68 minutes up to 83 minutes
6 units: 83 minutes up to 98 minutes
7 units: 98 minutes up to113 minutes
8 units: 113 minutes up to 128 minutes
The pattern remains the same for treatment times in excess of 2 hours. Providers should not bill for services performed for less than 8 minutes. If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time, see examples below.
Example 1: If 24 minutes of 97112 and 23 minutes of 97110 were furnished, then the total treatment time was 47 minutes; so only three units can be billed for the treatment. The correct coding is two units of 97112 and one unit of 97110, assigning more units to the service that took more time.
Example 2: If a therapist delivers 5 minutes of 97035 (ultrasound), 6 minutes of 97140 (manual techniques), and 10 minutes of 97110 (therapeutic exercise), then the total minutes are 21 and only one unit can be paid. Bill one unit of 97110 (the service with the longest time) and the clinical record will serve as documentation that the other two services were also performed.