Time as a Component of the E/M Codes

By W. Bruce Milliman, ND, and Eva Miller, ND (AMA - CPT/Editorial Panel/HCPAC, representing the AANP)

We are continuing our discussion on CPT coding for time. In this article we will discuss how to use time as a component of the Evaluation and Management (E/M) codes.  First office visits require that the following three components be documented in the medical record: History, physical examination and medical decision making. Based upon the extent of these components (detailed information may be referenced in the current CPT manual), a code numbered between 99201-99205 is used. For return visits, only two of the above three components need be documented, in order to justify use of codes numbered between 99211-99215. So, you may ask “where does time come in”?
The CPT manual states “When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.”
The take home message here is that if more than 50% of your visit is dedicated to counseling and/or coordination of care regarding a medical condition, you may be justified in using a higher level E/M code, so long as other components of E/M have been performed and documented.  Typical face-to-face time allotted for  (‘new patient’) codes 99201, -202, -203, -204, -& -205 are 10, 20, 30, 40 & 60 minutes, respectively. For (‘return office call’) codes 99211, -212, -213, -214 & -215, time allotments are 5, 10, 15, 25 & 40 minutes, respectively. Simply divide the relevant time increment by two to see if you patient interaction meets the time requirement relating to counseling and coordination of care
For example: Say you see a return patient and you document their chief complaint, then you do at least two review of systems, one social or family history and examine six systems with 2 elements per system and spent greater than 50% of the 25 minute appt. counseling or coordinating care you could use E/M code 99214.
Please note that any given insurer may choose not to recognize and reimburse for services coded and billed for, based upon counseling time.

We welcome your questions!