Is time the trump card in selecting an E/M service?

March 29th, 2009 - Codapedia Editor
Categories:   Coding   Documentation Guidelines   Evaluation & Management (E/M)   Primary Care|Family Care  
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Is time a trump card in selecting an Evaluation and Management service?

Sometimes.  Isn't that too frequently the answer in coding?

If the visit meets the criteria for using time ot select the code, and if time is a descriptor in the CPT® definition, then yes.

The criteria are:

  • Counseling dominates the visit.  More than 50% of the visit is spent in discussion with the patient of the patient's diagnosis, diagnostic test results, treatment options, importance of compliance, and patient education.
  • The clinician documents the total time of the visit, and that more than 50% was spent in the discussion
  • The clinician documents the nature of the discussion.

And, the CPT® code uses time as a descriptor.  Time is not a descriptor for observation, Emergency Department visits or preventive medicine codes, among others. 

If the above conditions are met, the physician may use time to select the code without regard to the level of history, exam or medical decision making.

For office services, count face-to-face time in the examining room.  For hospital services, count the unit time.

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