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Time-Based Evaluation and Management Services

The National Government Services Medical Review Department is currently performing service-specific prepayment audits on several families of E/M services as well as prolonged services.

Medical review results indicate that in some cases, when time-based codes are billed, the amount of time involved is missing completely from the documentation. In other cases, the records may specify the amount of time involved but lack documentation detailing what was actually done during that time. The purpose of this article is to assist in improving documentation so that it supports the billed services.

Some of the information below has been previously published in other articles. Parts of those articles are being republished to reinforce prior education.

Time-Based Services

It is essential that the documentation specifically state the amount of time involved in the service. Simply stating, for example, that you had a “lengthy discussion with the patient” is imprecise and subjective.

The preferred practice is to include clock times or start and stop times in your documentation, (e.g., “03/09/2008 3:15–3:55 p.m.”). In certain instances where this is not feasible, such as in inpatient settings where the total time is not continuous, a summary of time, or total time spent is acceptable.

Only the actual face-to-face time spent by the provider billing for the service can be considered in determining the level of E/M service. Time spent with the patient by other staff such as nurses and office assistants cannot be included in the face-to-face time.

Face-to-face time for office and other outpatient visits includes the physician performance of such tasks as:

    • obtaining a history
    • physically examining the patient
    • counseling the patient

Non face-to-face time includes such tasks as:

    • reviewing records and tests
    • arranging for further services
    • communicating with other professionals and the patient through written reports or telephone contact
    • discussing the patient with the family without the patient present

When billing time-based codes for outpatient services, do not include non face-to-face time in the total time for the service.

Counseling and/or Coordination of Care

Only when counseling and/or coordination of care constitute more than 50 percent of the face-to-face or floor time, will time be the key or controlling factor in E/M code selection.

Documentation in support of these services should include the following:

    • Total duration of face-to-face or floor time.
    • The duration of counseling or coordination of care and medical decision making.
    • A detailed description of the coordination of care or counseling provided. The documentation needs to provide sufficient information on what was coordinated and what was discussed or advice provided during counseling. Simple references such as “chart reviewed, RN consulted, reviewed Rx, etc.” is not sufficient.

The physician need not complete a history and physical examination in order to select the level of service. Time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

Time-Based Evaluation and Management Services
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