General Surgery Coding Alert

Question: One of our providers wants to bill an evaluation and management (E/M) visit using time, but they want to count the time spent with the patient, as well as the time spent preparing to see the patient. Isn’t time only calculated using face-to-face time?

California Subscriber

Answer: No. Leveling E/M counting only as face-to-face time is old-school. Prior to CPT® 2021 E/M office and outpatient updates, you counted only face-to-face time, but not any more.

CPT^® defines time for E/M coding as the total time (based on minutes) the provider spends on the date of service during which a provider personally rendered services related to the patient’s care, even if the times are not face-to-face and not consecutive. In other words, the time your provider spent preparing to see the patient is billable time and should be used when calculating the appropriate level of service.

As long as your surgeon accounts for services related to a patient encounter in the medical record and performs them on the same day, you can justify that time if an auditor questions it.

For example, if the surgeon documents reviewing the patient chart before the encounter and reviewing labs after the encounter, you can count that time to determine the appropriate E/M level.