Maximize Reimbursement for Care Coordination Services

by | Last updated Jun 9, 2023 | Published on Jan 4, 2017 | Medical Billing

Care Coordination Services
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Though physicians spend a lot of time counseling patients, they usually tend to overlook the reimbursement opportunity for this service. According to CPT guidelines, medical billing and coding for evaluation and management (E&M) services revolves around 7 components, 6 of which deal with the levels of services. These components are: history, examination, medical decision-making, counseling, coordination of care, nature of presenting problem, and time.

History, examination and medical decision-making are key components of the service. However, in the case of a face-to-face meeting with the patient, the physician can maximize reimbursement by reporting an appropriate E&M service using time as the qualifying element. In time-based coding for level of service, counseling/coordination of care must dominate or comprise more than 50% of the total encounter time.

The key time-based considerations of coding for coordination of care are as follows:

  • Documentation: For counseling/coordination of care, documentation should reflect:
    • Total time
    • Counseling time
    • Content of counseling or coordination of care
  • CPT reference times: The CPT reference times to determine the appropriate E&M service level for established outpatient codes are:
    • 99211 = 5 minutes
    • 99212 = 10 minutes
    • 99213 = 15 minutes
    • 99214 = 25 minutes
    • 99215 = 40 minutes

The code with the typical time closest to the actual time is used. For example, CPT 99213 should be reported if the time-based, established outpatient E&M lasted 18 minutes.

  • Location: Time calculation differs based on the location where the service is provided. In an office or outpatient setting, the face-to-face time between the physician and patient or the physician and the family members is considered. Floor or unit time is the determining factor in a hospital or nursing facility.
  • Reporting of prolonged services: Some payers (including Medicare) usually reimburse only for prolonged services with direct patient contact. In prolonged services involving a direct face-to-face physician contact with the patient, documentation should reflect at least an additional 30 minutes beyond the reference time of the chosen E&M service level. Another instance of prolonged services is that where face-to-face contact of the physician with the patient is not required. In this case, the physician can report the first hour of service using 99358, and each additional half hour with one unit of +99359. Prolonged services must reflect the patient’s ongoing management.
  • Care plan oversight (CPO) services: Physicians and qualified non-physician practitioners (NPPs) can bill Medicare and other payers for time-based CPO service. While CPO services do not require a face-to-face patient encounter, they require recurrent physician or NPP supervision of the patient. Medicare requires that the physician spends at least 30 minutes per month to bill for CPO. The CPT codes (99339-99340 and 99374-99380) depend on whether the patient is under the care of a home health agency (HHA) or hospice, the time spent each month, and the payer class.
  • Chronic Care Management: Starting Jan. 1, 2015, Medicare began paying for chronic care management (CCM). CCM services (CPT 99490) require at least 20 minutes of clinical staff time and may be billed once per calendar month. CCM services are those for which the physician or other qualified healthcare professional provides/supervises the management and/or coordination of services for all medical conditions, psychosocial needs, and instrumental and basic activities of daily living. The patient must have two or more chronic conditions which place him or her at significant risk of death, acute exacerbation/decompensation, or functional decline. The provider should develop, implement, continuously monitor and revise the comprehensive care plan as necessary for care.
  • Additional codes: There are CPT codes for services provided to patients via telephone (99441-99443) or online (99444), and for inter-professional telephone/internet consultations (99446-99449).

Experienced medical coding outsourcing companies have the knowledge and tools necessary to help physician take advantage of the revenue opportunities presented by time-based E/M services. Expert coders in these companies are aware about Medicare and private payer guidelines on payment for time-based services and also conduct regular audits to ensure that clinical documentation supports the selected code levels.


Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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