Decoding the CPT midpoint rule

The CPT midpoint rule, which says that “a unit of time is attained when the midpoint is passed,” applies to codes that specify a time basis for code selection. Though not accepted by all payers, even Medicare allows the midpoint rule for some services. For example, if you spend 16 minutes providing advance care planning rather than the 30 minutes included in the 99497 code descriptor but meet the other requirements, you can still bill for it because you exceeded 15 minutes. You must document the time, and you cannot include in your total any time spent on separately billable services (e.g., evaluation and management of chronic conditions).

Note that the midpoint rule only applies when no code or code-range specific instruction provides other guidance. For example, chronic care management code 99490 is not reported for less than 20 minutes of clinical staff time per code-level instruction.

Many E/M codes including office visit codes may be selected based solely on time instead of key components when counseling or coordination of care accounts for more than half of your total face-to-face time with the patient. When billing Medicare or other payers that do not always recognize the midpoint rule, your time must meet or exceed the typical time listed for the code you submit. Other payers may allow you to treat the typical times as averages and submit the code whose typical time is closest to the time spent with the patient (i.e., report a higher level when the midpoint between two levels of service is passed).

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