Coding Time-Based Services

The previous installment of “Spotlight on CPT” presented information regarding the determination of “time” for applicable codes. The CPT classification has time as a basis for many codes such as:

E&M codes

Administration of hydration, infusion, and chemotherapy codes

Telemedicine

Physical Medicine and Rehabilitation

Psychotherapy

This is by no means a comprehensive list but does give a coding professional an idea of where many time-based codes are found.

There are certain standards that are applicable to all time-based codes. These include:

Time is determined based on face-to-face time with the patient.

The mid-point of a unit of time must be passed in order to assign the time unit.

Example: If the time unit is 15 minutes-8 minutes must pass to capture the 15 minute unit.

Some codes with time-based criteria for assignment are governed by specific guideline instructions, parenthetical notes, or code descriptions. These include some E&M codes. There is a time threshold associated with those codes, which is based on total time on the encounter date. The concept of the mid-point would not apply for code assignment in those categories. For example:

98002 Synchronous audio-video visit for the evaluation and management of a new patient,

which requires a medically appropriate history and/or examination and moderate medical decision making.

When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.

For this example, it would be inappropriate to assign 98002 if only 25 minutes of total time was achieved, even though this is more than halfway to 45 minutes. In addition, if 43 minutes of total time was documented, it is still inappropriate to assign 98002 since the entire 45 minutes was not met. The coding professional must assign the code 98001 for total time of 30 minutes met or exceeded.

If another service happens to be performed along with a time-based service, coding professionals should exclude the time for the other service from the calculation of the time-based service code.

Prolonged services code assignment (99417, 99418) requires the full 15 minutes of time in order to report any unit.

Additional information for coding time-based services can be found in the E&M Services Guidelines section of the CPT manual.

Now, light has been shed on coding time-based services.

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.

Complex Migraine with Unilateral Weakness

“In the kNOW” this month will be covering the 2nd Quarter 2025 Coding Clinic topic of a complex migraine with unilateral weakness. To start, let’s find out more about a complex migraine. This type of migraine can cause a patient to exhibit symptoms of a stroke. There are several different types of migraines that are categorized as complex. They include hemiplegic migraines, atypical migraines, or migraines with aura. An aura is a period of time prior to the migraine during which sensory or neurological disturbances occur. Auras can include issues with vision, cognition, motor skills, or sensory perception.

Hemiplegic migraines are a subtype of migraines with aura. This rare type of migraine will present with motor weakness. Generally, it is more common for the patient to experience visual symptoms as an aura, but as noted above, patients may also experience impairment in their mental status, sensation, or even speech difficulty.

Here is a scenario for review:

A patient presents to the ER with the following symptoms:

Left-sided face, arm, and leg weakness 

Photophobia of the left eye

Right tongue deviation

Twitching of the left side of the face

These symptoms prompted an immediate stroke evaluation. A CT scan of the head was obtained, and a stroke was able to be ruled out. The patient’s final diagnosis was left-sided facial droop and left-sided weakness due to a complex migraine.

What is the correct code assignment for the left-sided weakness for this scenario?

The advice from Coding Clinic refers us back to a previous Coding Clinic from the 1st Qtr. 2015. In that issue, advice was provided on how to code for unilateral weakness when it is associated with a brain disorder. Coding professionals were directed to code that to hemiplegia/hemiparesis. With a migraine being considered a type of brain disorder, we can now reference the index to determine the appropriate code assignment.

 

Alphabetic Index: 

 

 

 

Tabular Index 

This 2nd Qtr. 2025 advice reminds coding professionals that older advice may need to be referenced in order to answer a coding question.

Now you are In the kNOW!!

 

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.