FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.

FREE PREVIEW. Purchase online access to read the full version of this article.

Fam Pract Manag. 2016 Jan-Feb;23(1):34.

Author disclosure: no relevant financial affiliations disclosed.

Coding based on time


I understand that physicians can bill E/M visits based on time or the levels of history, exam, and medical decision-making. If a physician billed the E/M service based solely on time but documented the history, exam, and medical decision-making, would that be acceptable?

That would not be acceptable unless the documentation also indicated that the requirements for time-based billing were met. If more than 50 percent of the face-to-face time of the encounter was spent counseling or coordinating care, coding based solely on time is permissible. The key components of history, exam, and medical decision-making may be used to determine the level of any E/M visit and must be used if the visit doesn't meet the criteria for time-based coding.

The 1995 and 1997 E/M guidelines include differing instructions for coding based on history, exam, and medical decision-making, but the instructions for coding based on time are the same: Document the total length of the encounter (face-to-face or floor time, as appropriate), note that more than 50 percent of that time was spent providing counseling or coordinating care, and provide examples (e.g., “answered patient questions regarding withdrawal and weight gain and gave recommendations for diet and exercise in addition to smoking cessation plan”).

About the Author

show all author info

Cindy Hughes is an independent consulting editor....

Author disclosure: no relevant financial affiliations disclosed.

These answers were reviewed by members of the FPM Coding & Documentation Review Panel, including Kenneth Beckman, MD, MBA, CPE, CPC; Robert H. Bösl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; Emily Hill, PA-C; Joy Newby, LPN, CPC; and Susan Welsh, CPC, MHA.


Send questions and comments to, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.


Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz


Sep-Oct 2016

Access the latest issue of Family Practice Management

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free FPM email table of contents and e-newsletter.

Sign Up Now