USING TIME IN EVALUATION AND MANAGEMENT LEVELING

Updates to the AMA CPT Evaluation and Management section have revised the use of time in the leveling of services provided.

EMERGENCY DEPARTMENT:

E/M services are never leveled based on time. The nature of these encounters involves variable intensity and multiple encounters with several patients over an extended period. Therefore, these encounters are leveled using MDM.

TIME-BASED ENCOUNTERS:

Time-based encounters, such as Critical Care, are not based on MDM; however, time is used differently. Careful review of instructions for each category is recommended.

TIMES:

Times have been updated within the E/M services description for each subsection and level. These times require a face-to-face encounter with the physician or other qualified health care professional and the patient and/or their family or caregiver. For coding purposes, the total time on the date of service is used. This includes both face-to-face and non-face-to-face time spent by the physician or other qualified health care provider on the day of the encounter. It does not include time spent on the performance of services separately reported, such as laceration repair or fracture reduction. This time also does not include time spent on activities provided by clinical staff.

SHARED OR SPLIT VISITS

Shared or split visits are defined as a visit where the physician and qualified health care professional both provide face-to-face and non-face-to-face work related to the visit.  When time is used in leveling, the time personally spent by the physician and other qualified health care professionals on that date of service can be combined to define total time. Although, any time spent when two or more individuals jointly meet or discuss the patient, only the time of one individual should be counted.

PROLONGED CARE

Prolonged care may be reported based on the total time spent on the date of the encounter spent caring for the patient. Time should be documented in the medical record.

Documentation of counseling greater than 50% of the time is no longer required when using time as the determining leveling factor.

Physician or other qualified health care professional time includes the following face-to-face and non-face-to-face time performing these services:

• Preparing to see the patient, such as the review of test results
• Obtaining or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering of medications, tests or procedures
• Referring & communicating with other health care professionals (when not separately reported)
• Documenting clinical information in electronic or other health records
• 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 is reported separately
• Travel
• Teaching that is general and not limited to discussion that is required for the management of a specific patient

“NOT SEPARATELY REPORTED”

“Not Separately Reported” means that the time the provider spent performing another service is defined by a CPT code that is separately reported (billed). This time is not added into the total time used to determine the E/M level of service. The time spent on the procedure is carved out of the total time.

TIME CLARIFICATION:

• If a test or study is independently interpreted to manage the patient as part of the E/M service, but is “not separately reported,’ it is part of medical decision making and the time may be counted toward the E/M level.
• If an independent interpretation and report for an EKG is done to manage the patient as part of the E/M and is “not separately reported,” it is part of the medical decision making and the time may be counted toward the E/M level.

Anne Mettler-Huebner, MT(ASCP), CCS, CCS-P, CPC, CPC-I

Auditor | Excite Health Partners

Sources:

• AMA CPT 2023 Professional Edition
• AMA CPT E/M Companion 2023