Recorded at HEALTHCON 2024 in Las Vegas, NV
During a panel discussion, participants raised questions about time-based billing for evaluation and management (E/M) services in outpatient settings, particularly regarding counseling for patients and caregivers. The importance of clear documentation and the thought process behind visit notes was emphasized, as well as the role of auditors in reviewing past notes.
The conversation also touched on the need for clarification on billing practices and the intent behind non face-to-face visits. Overall, the panel aimed to address concerns and provide guidance on best practices in documentation and billing.
Time-based E/M when only family or caregivers are present
Don’t bill office/outpatient E/M without the patient present. The panel’s read is that these codes assume a face-to-face encounter, even though the guideline phrase “patient and/or family/caregiver” can be misread.
Expect clarification from CPT®. The AMA team acknowledged the ambiguity and will work on language to make intent explicit; watch for CPT® Assistant or other official updates.
Use the right family-only codes where they exist. Some family psychotherapy codes allow time with caregivers without the patient; office/outpatient E/M typically does not.
Auditing data review across visits
Audit the note in front of you. Auditors shouldn’t need to dig through prior encounters unless the provider explicitly references a past item to complete today’s story.
Avoid “double-dip” credit. You can count the review of a test once (when ordered or when first reviewed). Re-stating the same review at every visit doesn’t earn new credit unless there is a documented clinical reason (for example, comparison that drives a decision today).
Show how the data changed your thinking. If you reviewed something, say what it showed and how it influenced today’s plan. Raw imports into the EMR don’t prove clinician review.
Documenting time the smart way
Always state total time on the date of the encounter. CPT® requires the total; payers may ask for more detail, but CPT® avoids piling on prescriptive breakdowns.
Tie time to medical necessity. If you spent 50 minutes on a “simple” complaint, explain the why (for example, complex counseling, risk discussion, caregiver education, prior hospitalization).
Keep templates honest. If your time statement lists “reviewed labs and x-rays,” make sure those items are actually in the record and used in your decision-making.
Exclude separately billable services. Make clear that your E/M time does not include time for any procedure or service reported separately.
Vary when reality varies. Identical time for every visit is a red flag; document the actual minutes, not a default.
“Curbside” or brief consultations on inpatient services
Write notes other clinicians can use. List what you reviewed, what you thought about it, and how it changed the plan; “Reviewed tests, agree with provider, total time 7 minutes” lacks clinical utility.
Be concise but substantive. The goal is continuity of care first, billing second. Capture the reasoning, not just an itemized checklist.
Practical auditor and provider guardrails
Providers: Tell the story. Who was present, what you did, what you reviewed, and why it mattered today. More words aren’t always better, but no words are never enough.
Auditors: Score what’s documented today. Credit data review once, confirm source and use, and resist retroactive scavenger hunts unless the note directs you there.
Everyone: Remember the hierarchy. CPT® sets the structure, payers may add policy, and medical necessity sits over all of it.
Quick wins you can apply tomorrow
Add a one-line “why” to time-based notes. “Spent 32 minutes counseling daughter on home safety and med management due to patient’s advanced dementia; updated care plan accordingly.”
Drop a comparison sentence for reused data. “Compared CT from 10/12 to 8/30; no interval change, so we will continue conservative management.”
Tune your templates. Remove boilerplate that claims reviews you didn’t perform; add prompts for “how did this affect today’s plan?”
Watch for AMA clarifications. Monitor CPT® Assistant and society newsletters for the forthcoming guidance on caregiver-only encounters.