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Evaluation and management (E/M) services are at the core of most family medicine practices and represent a category of Current Procedural Terminology (CPT) codes used for billing purposes. There are different levels of E/M codes, which are determined by the physician’s or qualified health professional (QHP)’s medical decision-making (MDM) or time involved.
You can maximize payment and reduce the stress associated with audits by understanding how to properly document and code for E/M services.
Generally, it's appropriate to use total time to select the level of service for a patient encounter when the amount of time the physician or other QHP spends on the date of the encounter performing visit-related activities before, during, and after the visit exceeds the MDM involved.
Time includes all activities (both face-to-face and non-face-to-face) related to the encounter performed by the physician or QHP on the date of the encounter. This includes activities such as reviewing external notes/tests/etc. not separately reported (billed), performing an examination, counseling and educating the patient/caregiver, and documenting in the medical record. Time spent performing activities normally completed by ancillary staff should not be included, and neither should travel time.
The only time that can be included in the calculation of total time is the time personally spent by the physician or QHP on the date of the encounter. Again, ancillary staff time cannot be counted; this includes medical assistants, patient care technicians, licensed vocational nurses, licensed practical nurses, etc. Any activities that occur on a separate date cannot be counted. For example, if you were to complete your documentation the day after the face-to-face encounter, that time could not be included when selecting the level of service.
Time related to activities that are reported separately (e.g., X-rays, lab tests, stress tests, etc.) should not be counted toward total time.
Total time on the date of the encounter may be used alone to select the appropriate code level for the following E/M services:
Time cannot be used to select the level of service for emergency department visits. The level of service is based on MDM. This does not differ from the previous guideline. However, the MDM levels have been modified to align with those for office visits (see below).
Time may be used to select the level of service regardless of whether counseling dominated the encounter. The definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes activities such as:
Time spent in activities normally performed by clinical staff (e.g., time spent by nursing or other clinical staff collecting a patient’s history) should not be counted toward total time. Furthermore, time spent on a date other than the date of service should not be counted toward total time.
For example, completing documentation on the day after the encounter would not be counted toward the total time when selecting the level of service for the encounter.
Finally, time spent on services that are separately reportable (e.g., independent interpretation and reporting of test results, tobacco cessation counseling) should not be included in total time calculations.
Each code has a specific time range. Physicians should ensure they document the total time spent on the date of the encounter in the patient’s medical record. Physicians should avoid documenting using time ranges and instead document specific total time spent on activities on the date of the encounter.
No, only the time personally spent by the physician can be counted toward total time. Since a scribe works in tandem with the physician during the encounter, the physician is getting credit for documenting in the record. The AMA is clear that any activities by ancillary staff should not be counted toward total time.
Any time spent on activities that are reported separately would need to be subtracted from total time used to select the level of E/M service. For example, if you spend 20 minutes conducting an annual wellness visit and a total of 50 minutes on activities for the encounter, you will only count 30 minutes toward the E/M portion of the encounter. A separate documented encounter is needed to reflect a separately identifiable service, because the 25 modifier may be needed for the E/M service. Ensure your documentation fully supports the medical necessity of both services reported.
There is no official guidance on what needs to be documented for total time. Your documentation should be sufficient to support the level of service billed. It is best to document the activities related to the encounter along with a statement that includes the total time for the encounter. Try to avoid providing a “cut-and-paste” generic statement of time because that is a red flag for auditors. Be specific about the services you performed for this patient.
A split or shared visit is when a physician and other QHP act as a team in providing care for the patient, working together during a single E/M service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.
When providing a split or shared visit, the time personally spent by the physician and QHP on the date of the encounter is summed to select the appropriate level of service. However, only distinct time should be counted. When there is overlapping time (e.g., jointly meeting with or discussing the patient) only count the time of one individual. When code selection is based on total time on the date of the encounter, the split or shared service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service.
Additionally, and as noted above, time spent on activities reported separately cannot be included in the total time used to select the level of E/M service. In those instances, you should include a statement specifying the total time does not include time spent on such services. For example, for an encounter that included the removal of a skin tag, you could include a statement such as, “Removal of the skin tag from the patient’s right armpit took 16 minutes. It was not included in the total time of the visit and was billed separately.”
Finally, do not use standard or template times for your documentation because that can be a red flag for auditors. For example, do not document that each Level 3 encounter lasted exactly 20 minutes or that each encounter included 15 minutes related to documenting in the EHR. Your documentation should reflect the actual time spent for each encounter.
No, the rules for teaching physicians have not changed. Only the time personally spent by the teaching physician and related to the encounter can be included in the calculation of total time.
The CPT Panel made additional modifications to the prolonged services codes. Prolonged services codes may only be used when total time has been used to select the level of service.
The revised prolonged services codes are listed below:
Prolonged services with direct patient contact (except with office or other outpatient services) CPT codes (99354, 99355, 99356, and 99357) have been deleted.
Medicare does not cover CPT codes 99417 and 99418, and as of January 1, 2021, it no longer covers prolonged services without direct patient contact CPT codes 99358 and 99359. Instead, physicians can report prolonged services for Medicare patients using the following HCPCS codes:
Like CPT codes 99417 and 99418, HCPCS codes G2212, G0316, G0317, and G0318 can only be used when time is used to select the level of service. They are add-on codes to and may only be used for increments of at least 15 minutes.
The difference between the CPT codes for prolonged services and the HCPCS codes is the time threshold that must be exceeded before the code can be reported. HCPCS codes G2212, G0316, G0317, and G0318 can only be reported once the maximum time for the highest level of service has been exceeded by at least 15 minutes.
Yes, both Medicare and private payers have adopted the new guidelines. Additionally, adoption of the increased values will vary based on a physician’s contract with the payer. Physicians should contact their local provider relations representatives to discuss incorporating the increased values into their contracts.
There’s no specific guidance to determine which method to use. You should use the method that most appropriately captures the work performed during the encounter. For example, for an encounter during which the patient had many questions and the level of MDM was lower, it may make more sense to select the level of service using time. Conversely, if an encounter was brief but required a higher level of MDM, it may be appropriate to select the level of service using MDM. Whichever method you use, include sufficient documentation to justify the level of service billed. Additionally, document based only on the method you used; do not document both time and MDM for the same encounter, because this could confuse auditors.
Many private payers have implemented downcoding programs, where the payer lowers the level of service submitted on the claim. Payers most frequently downcode claims with a higher level of E/M service when the payer believes the diagnosis submitted does not warrant the level of service billed by the physician. Some payers have instituted claim edits that automatically downcode the claim without first requesting documentation from the physician. The AAFP has and continues to advocate with payers to provide clear communication and education to physicians regarding downcoding programs. Specifically, the AAFP advocates that payers provide transparency into any program whereby physicians may be identified as outliers. The AAFP also advocates for simplified appeals processes and for appeals to be processed in a timely manner. The American Medical Association developed a guide to payer E/M downcoding programs (Payer E/M downcoding programs: what you need to know).
Medicare increased the relative value units of many E/M codes in conjunction with the associated descriptor and documentation changes. Physicians can look up the current values and allowed amounts using the Medicare Physician Fee Schedule Lookup Tool.