A: Per time guidelines, only time spent on the date of the patient encounter can be counted towards the total time spent for leveling the Evaluation and Management service. If documentation is occurring on a different day, it cannot be counted.
Q: So, there are times when a surgery with a global of 10 days could be considered a major procedure? This is different than in the past.
A: Yes, according to the AMA the “classification of surgery into major or minor is based on the common meaning of such terms when used by trained clinicians…”
Risk factors that are inherent to the procedure (bleeding, puncturing the lung, etc.) and risk factors related to co-morbidities of the patient might be some examples.
The documentation should support the risk of the procedure.
Caveat: The simple existence of co-morbidities will not make a generally minor procedure a major procedure.
Q: The 2023 changes say that the new MDM or total time spent guidelines apply to all E/M services. What about transitional care management (TCM)?
A: Beginning in 2023 ALL E/M services will follow the new set of guidelines. TCM codes 99495 and 99496 are considered outpatient E/M services and follow the new guidelines.
Shea Lunt, RHIA, CPC, CPMA, PMP
Shea is a consultant for The Haugen Consulting Group with 11 years of health care industry experience. Shea has experience working on the professional fee side of coding, auditing, education and compliance serving coders and physicians.
She earned a bachelor’s degree in health information management and a master’s degree in health services administration from the University of Kansas. Shea is a Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and a Project Management Professional (PMP).
Shea, her husband, and their daughters, call the wide-open spaces of central Kansas home.