Mental Health Blog

Why Clinicians Should Consider Coding by Time for Mental Health Care

• November 21, 2024
• The REACH Institute
• Coding, Pediatric primary care

“Many primary care providers are still coding by medical decision-making for mental health care,” explains Eugene Hershorin, MD, a REACH faculty member and medical coding expert. “However, time-based coding is both easier and often results in higher coding levels and therefore higher payment rates, especially for pediatric patients who require ongoing care for mental health conditions.” 

One reason for the lower uptake is that the benefits of time-based coding are relatively new. In 2021, the Centers for Medicare and Medicaid Services (CMS) released major updates to coding guidelines for office-based evaluation and management (E/M) services. One of the biggest shifts made it much easier for clinicians to bill for mental health services based on time spent working on a patient’s case on the date of service. 

Dr. Hershorin walks us through how time-based coding can enable clinicians to better support long-term wellness for children and adolescents with mental health conditions. 

The Old Status Quo: Coding by Medical Decision-Making

Prior to 2021, coding by medical decision-making was the norm for mental health care services in primary care settings. Dr. Hershorin aptly describes this type of coding as “counting bullet points to be sure there are enough to code and be paid for services.” 

In coding by medical decision-making, the level of the visit (a significant factor in the payment rate) is determined by: 

• Number and complexity of problems address
• Amount and/or complexity of data reviewed and analyzed
• Risk level

To code a visit from levels two to five, the visit must meet certain criteria within each category, all tracked and documented by the clinician. For example, to qualify as a level five visit, a patient must present with a worsening condition that is complex and presents a high risk to their health and safety, such as a depressed adolescent who may need hospitalization. 

A significant downside of coding by medical decision-making is that it keeps payment rates lower when treating patients whose mental health conditions are well-managed. Standard visits with such patients may be difficult to code above a level two or three visit. 

Time-based coding is one way that clinicians can ensure that they are paid adequately not just for managing pediatric patients in a mental health crisis, but for ensuring that those who are doing well with appropriate treatment continue to thrive. 

How Time-Based Coding Benefits Patient Mental Health Care

Coding by time for mental health care is simpler but does require tracking time spent on the patient on the date of service. The coding level of the visit is determined not by risk, crisis, or complexity level, but by how much time you spend on that patient’s care throughout the course of the date of the visit. Both face-to-face time and non-face-to-face time, such as time spent charting, waiting on hold for the pharmacist, reviewing previous visits, scoring rating scales, etc. count toward the total.

For example, for an existing pediatric patient whose ADHD is well-managed, a clinician might spend 7 minutes reviewing previous visits to prepare for the visit, 15 minutes during the office visit, 8 minutes charting after the visit, and 17 minutes speaking with other care providers such as pharmacies, labs, or other health care professionals, typically limited to those outside the practice and/or billing under another tax ID. 

Under time-based coding, this could qualify as a level five visit that would be documented with a note stating: “This was an office visit that took 47 minutes and included reviewing notes from the past three visits, face-to-face time with the patient, charting time, and time speaking with the pharmacy.”

Extended Time Codes

When using time-based coding, if time spent on the patient goes beyond that of a level-five visit, clinicians can also use the prolonged service code (99417). Prolonged services can be billed in 15-minute increments. For example, if a clinician spends 32 additional minutes beyond the 54 minutes allocated to a level-five visit with an existing patient, they can bill twice for prolonged service.

Integrating Coding by Time Into an Existing Practice

If you are coding pediatric mental health care by medical decision-making, the biggest change is making the switch to record what you, as the clinician, are doing and how long each activity takes. 

Time-based coding applies for both in-office and telemedicine visits. However, time-based coding cannot include clinical staff time, resident time, or time spent on other days. That means you will need to complete charting and all other activities on the same day as the office visit. 

RESOURCES

• When the new CMS guidelines went into effect in 2021, Dr. Hershorin recorded an in-depth coding webinar for REACH. As of 2024, no additional significant changes have been made by CMS, which means the webinar remains a valuable resource for clinicians. 
• For a quick recap of the 2021 CMS changes, REACH’s prior article on the topic provides a brief overview.
• For those looking to go more in-depth or have a resource on hand, Dr. Hershorin recommends the book Current Procedural Coding Expert (Optimum 360).