13: Medical Billing With Time

Understanding Time-Based Billing

Beth Blimmer: Alright, welcome back to Starting Strong! This is Beth with Mark and Vicky, and today, we're wading into something I know *nobody* finds thrilling, but, it's so vital—time-based billing. Stick with us, I swear this stuff pays off—literally!

Mark Krause: Yeah, and I mean, look, we've all had those days where you've done, like, two hours' worth of family meetings, med reconciliation, wrestling the case manager for discharge planning... and you think, "Wait, what did I just bill for? Was that even reflected?"

Vicky Muller: Exactly, and sometimes, all that effort just vanishes if you don't document it right. But before we jump into nuts and bolts, let’s clarify—when do you *actually* use time-based billing instead of the usual medical decision making or MDM, right?

Beth Blimmer: Totally, it’s not every case. I generally do MDM as the default. But, time-based is clutch when your total time doing care coordination, counseling, or just wrestling with records, outpaces the actual complexity of decisions—or when you’re in those long patient-family conferences. I remember this one complex discharge where we spent, like, an hour breaking everything down with the family. Before I got wise, I'd just bill on complexity and basically 'lose' all that effort. But if you count and document that time? That’s real billable work.

Mark Krause: Yeah! And to Beth’s point, scenarios that are often overlooked are sometimes patients are sick enough to bill critical care time but we don't think about because we are used to the complexity. Or, billing for advanced care planning like goals of care. These can actually be done in addition to our MDM billing or swapped depending on the setting.

Vicky Muller: Oh, and heads up, time-based billing wants pretty specific documentation—not just “Spent lots of time.” It’s got to hit things like prepping to see the patient, reviewing records, counseling family, rounding up consults, orders... all on the *same* date as the encounter.

Beth Blimmer: And don't forget care coordination, reviewing outside records, even rounding up other providers! But, classic pitfall here—don’t let that time overlap: you can’t count the same minute for two patients, or stack up with another physician in your group on the same encounter. And... don’t go wild and document like, five hours on a 30-minute visit. Auditors really, really don't like magic time.

Mark Krause: Right, “creative” time keeping is a hard no. But track it honestly, document what you did, and suddenly you’re not working for free. Seriously, just a few changes to how you log your process can totally shift your billing. And if all those terms are new, don’t sweat it—we’re building on earlier episodes about RVUs and MDM billing.

Prolonged Care, Records Review, and Critical Care

Mark Krause: Alright, let’s kick into prolonged care and records review. So, prolonged care is what you bill if you blaze past those regular time thresholds for initial or follow-up visits. Like, say you’re with a patient for over 65 minutes in one day—you've crossed into “prolonged care” territory and can bill codes like 99418 for each extra 15-minute chunk on top of your base code.

Vicky Muller: Yeah, and it's not just face-to-face. Non-direct care counts, too—think updating the chart, calling specialists, reviewing the labs the marathon-long way. Just remember, it all has to add up *on the same calendar day*, and only one person can bill it per group per patient per day.

Beth Blimmer: I always mess this up in my head—wait, is it less than 65 minutes is nothing extra, 65–79 is one prolonged code, 80–94 is two, right?

Mark Krause: That’s it! And if you ever cross that magical 95 minutes, you just keep stacking more 99418s. But don’t forget, if you’re using MDM complexity, you can’t just also toss in prolonged codes. It’s one or the other: total time billing *or* MDM. the good thing is MDM has a conversion to time so you can see where your based time is and if you can add on more.

Vicky Muller: And records review—that’s still a gray area for hospital medicine, but if you ever spend more than 30 minutes pre-charting or catching up after discharge on a separate calendar day, you can bill for that time, too. But you need a really clear attestation: exact times, and that it was without direct patient contact, tied to a particular E&M visit.

Mark Krause: Right. Let’s run through two for critical care time cases. First, think about a type 1 diabetic in DKA, on an insulin drip, unstable vitals—this is ongoing, hands-on management. If your care meets critical care criteria (like addressing shock, abnormal labs, immediate threats) and it takes over 30 minutes, that’s critical care billing, not just a high-level follow-up. Make sure your note lists total critical care time and details how you were immediately available for interventions, evaluations, and those high-stakes decisions.

Vicky Muller: Sometimes we forget how sick these patients really are and that critical care billing could be applied. At a smaller hospital this patient may be in an actual ICU for monitoring so keep that in mind. Drips can be a good marker for critical care time, especially if you expect something emergent would happen if the drip was stopped--insulin for DKA, cardeen for hypertensive emergencies, Cardizem for atrial fibrillation with RVR all could qualify.

Beth Blimmer: Or the ESRD patient with sky-high blood pressure, rising lactic acid, and dynamic EKG changes—again, tons of intensive management, high likelihood of deterioration. That’s critical care, and *location* doesn’t matter. As long as your care met the definition of being immediately available and you weren’t running around attending to other patients in that exact span, you can bill that critical care time. But if you split your attention or slip under 30 minutes, you might lose out or have to just bill a regular E/M.

Mark Krause: Yeah, and don’t forget you need a very clear attestation: critical care requires start and stop times, what you did, and why it was critical. And as always—when in doubt, over-document, not under!

Advance Care Planning, Caveats, and Getting It Right

Vicky Muller: So, let’s move on to advance care planning—ACP. These are those often emotional, super important conversations about code status, future wishes, or setting up formal directives. If you spend a minimum of 16 minutes, face-to-face, with the patient or their surrogate—even including completing forms like a TPOPP—that’s billable under ACP codes.

Mark Krause: Yeah, and don’t shortchange yourself by leaving that time on the table. Document not just that you had the conversation, but the minutes spent, the topics covered, and that it was face-to-face. And these can be real difference-makers—both for families and for your bottom line. Just got to hit that minimum, at least 16 minutes.

Beth Blimmer: But here's the part that trips folks up: you can’t double-count your time—say, for an admission H&P and the ACP conversation that overlaps. Also, keep an eye on your cumulative time if you work across a long shift; don’t let your entries stack up to something wild like 10 hours for a single patient or overlap the overnight with a colleague’s efforts. Auditors will see through that.

Beth Blimmer: Great point. the 16 minute threshold has to specifically be about goals of care. I see people do an admission and then have a quick code conversation. You know, the easy one where they clearly want full code. Some people will bill for ACP planning but that 16 minutes wasn't there.

Vicky Muller: Totally. A good time to use it is when things are not clear cut. I had a recent tricky case—a family just couldn't agree on a code status for, honestly, hours. The team sat down together, documented exactly when the conversation started, ended, who was involved, and all the separate counseling bits. It ended up being billable both as ACP and as time-based care since we’d clearly separated it from the H&P. Accurate time-stamping and detailed notes made all the difference; we covered our compliance bases, got proper credit, and helped the family reach a decision.

Mark Krause: I love it. It's really about being honest, detail-oriented, and not letting your hard work go unrecognized—just like with consults and peer-to-peer calls from earlier episodes. Little adjustments mean fewer missed billings—and better support for your patients, too.

Beth Blimmer: So, to wrap up: learn these basics, bill *how* you practice, not just what looks easiest, and those small tweaks can really add up. We're not saying become a coder, but a little attention pays dividends.

Vicky Muller: Alright, thanks for hanging with us through the weeds! Next time, we’ll tackle more hospital medicine headaches. Mark, Beth—thanks guys, and see you soon.

Mark Krause: Catch you all next episode—don’t forget, if you have billing horror stories or wins, send them our way!

Beth Blimmer: Bye everyone—and remember, don’t work for free if you don’t have to!