Lori
Well-known member
Good Morning Coders!
What are you coding today?
Guidelines Common to All E/M Services
Time
The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the
CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 was done to assist in
selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for 99211, time
alone may be used to select the appropriate code level for the office or other outpatient E/M services
codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use
time differently. It is important to review the instructions for each category.
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. Therefore, it is often difficult
to provide accurate estimates of the time spent face-to-face with the patient.
Time may be used to select a code level in office or other outpatient services whether or not counseling
and/or coordination of care dominates the service. Time may only be used for selecting the level of the
other E/M services when counseling and/or coordination of care dominates the service.
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. 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.
A shared or split visit is defined as a visit in which a physician and other qualified health care
professional(s) jointly provide the 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 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 appropriate
time should be documented in the medical record when it is used as the basis for code selection.
Total time on the date of the encounter (office or other outpatient services [99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the
total time on the date of the encounter. It includes both the face-to-face 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).
Physician/other qualified health care professional time includes the following activities, when performed:
preparing to see the patient (eg, review of tests)
obtaining and/or reviewing 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 record
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
travel
teaching that is general and not limited to discussion that is required for the management of a
specific patient.
What are you coding today?
Guidelines Common to All E/M Services
Time
The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the
CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 was done to assist in
selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for 99211, time
alone may be used to select the appropriate code level for the office or other outpatient E/M services
codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use
time differently. It is important to review the instructions for each category.
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. Therefore, it is often difficult
to provide accurate estimates of the time spent face-to-face with the patient.
Time may be used to select a code level in office or other outpatient services whether or not counseling
and/or coordination of care dominates the service. Time may only be used for selecting the level of the
other E/M services when counseling and/or coordination of care dominates the service.
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. 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.
A shared or split visit is defined as a visit in which a physician and other qualified health care
professional(s) jointly provide the 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 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 appropriate
time should be documented in the medical record when it is used as the basis for code selection.
Total time on the date of the encounter (office or other outpatient services [99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the
total time on the date of the encounter. It includes both the face-to-face 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).
Physician/other qualified health care professional time includes the following activities, when performed:
preparing to see the patient (eg, review of tests)
obtaining and/or reviewing 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 record
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
travel
teaching that is general and not limited to discussion that is required for the management of a
specific patient.