Using Time to Make E/M and CMT Separate and Distinct
Editor’s Note: The ICS has an on-demand course with Dr. Gwilliam covering the entire -25 modifier issue and all of the tips here.
A clear method to defend E/M and CMT billing by documenting separate time blocks, strengthening the 25 modifier use, and improving payment outcomes for chiropractic physicians.
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Referenced Links:
E/M and CMT Bundling Prevention Toolkit
Paxson (ICS Trained AI)
Everything Chiropractic Physicians Need to Know About Evaluation & Management (E/M) Coding (Article)
Webinar – Everything Chiropractic Physicians Need to Know About Evaluation & Management (E/M) Coding
Transcription:
Marc:
So we believe this may be the last of our long series on all of the things related to E/Ms, CMT, and RVUs, diagnosis codes, and all of the different things that go into this whole mix. Again, we want our doctors to be appropriately paid for the services that you perform. You provide a good and valuable service, and you deserve to be paid for it. And so this last component that we really want to touch on, Dr. Gwilliam nails down a new concept that is a little bit different, but give us some background a little bit first before we dig into the nitty gritty of this one, because it seems really simple on the surface, but when we start talking about E/M, don’t go into full detail. I know that you could do a full webinar on this, but the difference in MDM and documenting time, when we start talking about what level of E/M you are performing.
Dr. Gwilliam:
Now, first, let me say that ICS members have access to a recorded webinar that does a deep dive on how to get the right level, and I can talk about E/M coding and picking the right code for days on end. But the E/M guidelines were dramatically updated change of 2021, and what they did was they said, instead of looking at these key components and stuff, you can choose your code based upon one of two elements, either the time that you’ve documented, or the medical decision making. And when it comes to medical decision-making, that’s all about your brain power and how much you have to work on it, and how complex it is for the patient. And you can read about that in the article available to you in ICS, and also watch the webinar. But then there’s the time element. And the way that that rule changed was it’s about all the time that is spent face to face with the patient and non-face-to-face. They say, if you document the time, that alone can be enough to explain. So, for example, if you hit 10 minutes, you can build a 99212; if you have 20 minutes, you can build a 99213, as an example for re-exams.
Now, what I’m going to do is I’m going to take that concept of documenting time and help it help us get paid for this. When we are challenging this bundling issue, we can leverage the concept so we can actually document time; it will help us in two ways. One, it will help support the level of the E/M service if we document sufficient time. But two, it’ll help us show that this service for the E/M was significant and separately identifiable from the CMT. And it’s actually really easy. What you do now it’s going to take a little bit of work. It’s going to take you an extra 10 seconds to type it into your note. Perhaps what you do is you say I took this amount of time to do the E/M service. Now, instead of just saying I took 20 minutes, put the start and stop times. Say I started my E/M at 12:33 pm and I ended it at 12:43 pm or 53 pm, whatever time it took. That makes it very clear that you weren’t spending that you weren’t spending that time doing anything else. You’re with the patient doing the exam. And that’s great, and that will help justify the level of E/M. But the key here for the 25 modifier, if you did a CMT that day as well, is you document a separate time block for the CMT. You say, Well, I know my exam was at 12:33, my adjustment was done either before or after the exam separately. It wasn’t done at the same time. I didn’t do a little of each and go back and forth. What I did was I did all the work that’s tied into adjusting a patient, and I documented that I did that from, you know, 12:25 to 12:33, or whatever the time was. And I did that, and it took me five minutes to do an adjustment. And you make it really clear in the notes, say, Here’s my adjustment. It happened in this timeframe. And then you pause, you take a breath, and you go to a new page in your record, which we talked about in another video. You say, Okay, at this time, I began to do my exam, or the other order, whichever you feel is most clinically appropriate based upon what you’re trying to do with your patient. But separate the time blocks. Document, take that extra time it takes to say the time you started to stop each separate service. And that makes it much, much harder for someone to claim that those services are the same service. They are totally separate. If I go back to my pie metaphor one last time, I made one pie and I stopped making that pie and I started making the next pie, you know, and there and I didn’t make them at the same time. And you’re telling that clearly your documentation. So that’s a powerful, powerful way to just break those apart. And, you know, good luck challenging it.
Marc:
And it becomes, yeah, it becomes inarguable at that stage, right. There’s no argument that can be made that they were bundled together because you clearly documented the time. So yes, it’s extra work. Yes, it’s an extra step. But when you bundle this, pardon the expression, but when you combine all of these different tips, right, all six of these areas that are covered in Dr. Gwilliams’ toolkit, at the end of the day, we believe that that creates this ironclad argument that becomes purely defendable, and actually offensive, right? It could ultimately be used in an offensive approach and and by the way, the you know, the Illinois Chiropractic Society has been really offensive on this as much as humanly possible. We have not just sat down and met with Blue Cross, Blue Shield time and time and time again with this issue and this bundling problem, but we’ve also actually sat down with the AMA and prompted the AMA to actually go through and make some modifications to the CPT Assistant. You can see some of that work that was done a handful of years ago, as well as we worked with the AMA to ensure that that got more appropriately identified. We still think that there’s work to be done there, but that’s a discussion for another day. But all of these things are ways that you can basically begin to empower yourself to win these arguments on appeal. Hopefully, we never have to get to the appeal. Hopefully, the claim forms tell that story up front, that your time documentation makes it clear, and when you send it in, ultimately it gets paid. And we can eliminate this 25 modifier situation where, ultimately, you win enough appeals, you demonstrated enough on your claim form, where we don’t see the denials anymore, and you are getting properly paid for the services that you’re rendering. You deserve to be paid for the services that you provide to your patients when you bring them back to health.
Dr. Gwilliam:
I’m going to say, I’m going to add, I believe this toolkit is the best information available, the best ideas that we’ve been able to come up with, researching, conversing with other experts, and making you as equipped as possible to get paid properly for the work that you’re doing. So we hope that you can leverage it and use this to be able to practice chiropractic while you’re getting paid and take care of more patients, and live happily ever after.
Marc:
There it is. Thank you all, and we’ll catch you next week.
