Ask the Expert

This month’s selection:

A recent conversation came up amongst our auditing team and we can locate no particular guidance. The team is of two minds: 1) the CPT definition of evaluation and management (E/M) total time cannot possibly apply to gynecology clinic services because of how those services have historically been reported, and 2) total time simply cannot serve as the basis of E/M selection in the gynecology clinic when any of these additional services are furnished.

AMA defines total time relative to evaluation and management services as not inclusive of “any time spent in the performance of other separately reported service(s)” (CPT, 13). Our question is: how should we interpret this statement in relation to gynecology clinic services, such as pelvic examinations and Pap smears? CPT code 99459 (pelvic examination, list separately in addition to code for primary procedure), HCPCS codes Q0091 (screening Pap smear; obtaining, preparing, & conveyance of cervical or vaginal smear to laboratory), Q0111 (wet mounts, including preparations of vaginal, cervical, or skin specimens), and Q0112 (all potassium hydroxide [KOH] preparation) are often furnished to patients in the gynecology clinic concurrent with evaluation and management services. The nature of these services, when performed, is such that they possess an overlapping relationship with the evaluation and management service. At the same time, if selecting E/M services based off time, what would be the most compliant documentation to support the E/M level?

Any advice or assistance is appreciated.

Kevin Blane Shields, D.Arts, RHIA, CCS, CCS-P
HIMS Facility Educator (MRA)

Response:

E/M total time refers to the physician/qualified health care professional time in evaluation of a patient. If other procedures and/or services are being performed and billed separately, then that time cannot be included in the E/M total time.

As referenced in the question, if the provider is performing a Pap smear and billing for that Pap smear, then that work (including the time spent performing that work) is captured in the code reported for the Pap smear.

When billing an E/M service based on time, the documentation should include the total time spent; this may include patient face-to-face and non-face-to-face time (eg, coordinating care with another provider after the patient leaves the clinic) and must be time spent on the date of the encounter. The documentation should include what the time was spent on. There are no specific documentation guidelines from the American Medical Association or the Centers for Medicare & Medicaid Services, but the CPT® manual does give information on what type of activity may be credited toward time.

It’s also important to note that clinical staff time does not count, the E/M time is strictly that of the provider/qualified health care professional.

— Leonta Williams, MBA, RHIA, CPC, CPCO, CRC, CEMC, CHONC, CCS, CCDS, is senior director of education at AAPC.