Documenting E/M Services by Time
CPT® guidelines allow you to report E/M services by time—that is, you consider time as the key or controlling factor to qualify for a particular level of E/M service. When reporting E/M services by time, per the CPT® Evaluation and Management (E/M) Service Guidelines:
- Counseling or coordination of care must dominate (more than 50 percent) the patient encounter.
- The E/M service to be reported must have a “reference time,” identifiable in the code descriptor by the statement, “Typically, xx minutes are spent face-to-face with the patient and/or family.” The reference time provides an objective standard by which to determine whether “more than 50 percent” of the visit is spent in counseling and/or coordination of care.
- In the context of office and other outpatient visits, “time” refers specifically to time spent face-to-face with the patient, as well as “time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members.” Time may include floor/unit time in the hospital or nursing facility.
- “The extent of the counseling and/or coordination of care must be documented in the medical record.”
The documenting provider must do more than state how long the service lasted, or that counseling or coordination of care dominated. Instead, the documentation should detail the content of the visit to support time as the controlling factor and to support overall medical necessity.
The best practice for providers when documenting E/M services by time is to record the total time of the visit, the total time spent in counseling or coordination of care, and a synopsis of the discussion. The note within the medical record can be a detailed summary of the activity with the patient, the recommendations, and the patient’s concerns. The provider also should document information from the history and examination, and from the MDM concerning reviewed tests, ordered tests, co-morbid conditions, etc., to further support the chosen service level and the time spent in counseling or coordination of care.