TIME

For the purpose of selecting the level of service, time has two definitions.

1. For office and other outpatient visits and office consultations, intraservice time (time spent by the clinician providing services with the patient and/or family present) is defined as face-to-face time. Pre- and post-encounter time (non-face-to-face time) is not included in the average times listed under each level of service for either office or outpatient consultative services. The work associated with pre- and post-encounter time has been calculated into the total work effort provided by the physician for that service

2. Time spent providing inpatient and nursing facility services is defined as unit/ floor time. Unit/floor time includes all work provided to the patient while the psychiatrist is on the unit. This includes the following:

• Direct patient contact (face-to-face)

• Review of charts

• Writing of orders

• Writing of progress notes

• Reviewing test results

• Meeting with the treatment team

• Telephone call

• Meeting with the family or other caregivers

• Patient and family education 

Work completed before and after direct patient contact and presence on the unit/floor, such as reviewing X-rays in another part of the hospital, has been included in the calculation of the total work provided by the physician for that service. Unit/floor time may be used to select the level of inpatient services by matching the total unit/floor time to the average times listed for each level of inpatient service. For instance:

99221 

Descriptor: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: 

• A detailed or comprehensive history 

• A detailed or comprehensive examination 

• Medical decision making that is straightforward or of low complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/ or family’s needs.

Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

The three questions are prompts that assist the auditor (usually a nurse reviewer) in assessing whether the clinician 1) documented the length of time of the patient encounter, 2) described the counseling or coordination of care, and 3) indicated that more than half of the encounter time was for counseling or coordination of care.

Important: If you elect to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or services or activities performed to coordinate care