Appropriate level of Evaluation and Management (E/M) services are based on Medical Decision Making (MDM) and time for services performed. In our previous article, we has a detailed discussion on how Medical Decision Making (MDM) affects E/M code selection and other factors involved. In this article, we will be focussing on guidelines for the selection of time-based E/M involving accurately counting time and the selection of time-based E/M codes. Note that, certain categories of time-based E/M codes that do not have levels of services based on MDM like critical care services in the E/M section use time differently. It is important to review the instructions for each category.
Guidelines for Selection of Time-based E/M Codes
- Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.
- When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional and the patient and/or family/caregiver. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.
- For coding purposes, the time for these services is the total time on the date of the encounter. It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). It includes time regardless of the location of the physician or other qualified health care professional (eg, whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported services (s).
- A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) both provide face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient and/or counseling, educating, communicating results to the patient/family/caregiver on the date of the encounter is summed to define total time.
- Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).
- When prolonged time occurs, the appropriate prolonged services code may be reported. The total time on the date of the encounter spent caring for the patient should be documented in the medical record when it is used as the basis for code selection.
Activities Contributing Towards Time
Physician or other qualified health care professional time includes the following activities when performed:
- preparing to see the patient (e.g., review of tests)
- obtaining and/or reviewing the separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- ordering medications, tests, or procedures
- referring and communicating with other health care professionals (when not separately reported)
- documenting clinical information in the electronic or other health records
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- care coordination (not separately reported)
Do not count time spent on the following:
- the performance of other services that are reported separately
- teaching that is general and not limited to the discussion that is required for the management of a specific patient
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