Per the evaluation and management (E/M) guideline changes of 2021, codes may be selected based on time alone. This is a big departure from the way time was used, as a infrequent option, in the past. In many ways it creates a very straightforward way for providers to select the proper code, but it also comes with several considerations.
E/M code selection based on time
The “total time” used for code selection is based on face-to-face time as well as non-face-to-face time spent personally by the clinician on the day of the encounter. It does not include time spent on activities normally performed by clinical staff, or on separately reportable services, and it doesn’t matter where the clinician is when doing the non-face-to-face work. It also would not include time spent shooting the breeze with the patient about their family or last night’s football game.
There are eight office/outpatient E/M codes that have time thresholds (99211 does not have a time element, and in fact, does not even require the presence of a physician). The time thresholds are as follows:
| Code | Total time (must be met or exceeded) |
| 99202 | 15 |
| 99203 | 30 |
| 99204 | 45 |
| 99205 | 60 |
| 99212 | 10 |
| 99213 | 20 |
| 99214 | 30 |
| 99215 | 40 |
The official guidelines offer a list of things that might be appropriate to count towards this time. They include:
- preparing to see the patient (eg, review of tests)
- reviewing separately obtained history
- performing an evaluation
- educating the patient or family
- ordering tests
- communicating with other clinicians
- documenting clinical information in the record
- independently interpreting results and communicating them to the patient or family
- care coordination
The instructions tell us that we are not to count time spent on the following:
- the performance of other services that are reported separately
- travel
- teaching that is general and not specific to a patient
There is no guidance on what verbiage should be used to document time, but it would be wise to consider listing a few of the items from above, verbatim, to support how the time was spent, and to support medical necessity. Specifying start and stop times would make the record even stronger, especially when the time is non-contiguous. For example, a provider could count the time spent scoring an outcome assessment and composing a care plan, even if it is a few hours after the patient left. It just needs to be the same calendar day.
Sample documentation of time for a 99213 might look like this:
“Physician spent 24 minutes of total time (not including separately billed procedures), from 11:24AM to 11:48AM, performing a medically appropriate examination, educating the patient, and documenting clinical information in the electronic record.”
Please note that there are no specific documentation requirements for time, but this kind of verbiage would make the documentation very defensible if challenged by a third party.
The time method seems fairly straightforward, but there are instances when it may not be the best option. For example, what if a new patient exam only takes 13 minutes? According to the time guidelines, that exam would not be billable. That’s where Medical Decision Making (MDM) can come into play. Part 4 of this blog series on evaluation and management coding and documentation for chiropractic is a deep dive into MDM. See parts 1 and 2 for even more.
Dr. Gwilliam is the Senior Vice President of Practisync, which helps practices improve efficiency and collect more through outsourced expert billing services. You can reach out to Dr. Gwilliam at evan.gwilliam@practisync.com.