Properly documenting time in E/M visits

To paraphrase the Rolling Stones, time is on your side in certain patient visits (yes, it is) – but only if you document it.

Most evaluation and management (E/M) services are selected based on the level of history, exam, and medical decision making documented in the note. But if counseling, coordination of care, or both dominate the visit, CPT instructs physicians to select a code based on time. By the way, CPT defines “dominates” as a physician spending more than 50 percent of the time on that activity.

This is implemented differently for office and facility services.

In the office, a physician selects the level of service based on face-to-face time, when more than 50 percent of that time is spent discussing with the patient and family the diagnosis, prognosis, risk and benefits, instructions for management, and education. You can count only face-to-face time. Time spent out of the exam room reviewing records, viewing images, or completing documentation cannot be counted when selecting the level of E/M service.

In the hospital or other facility setting, on the other hand, the total time calculated to determine the level of E/M service not only includes the face-to-face time spent counseling or coordinating care with the patient and family but also any time spent on the unit in general coordinating the patient’s care. You still must spend more than 50 percent of your time on counseling or coordination.

To properly document your time, use statements like these:

“I spent 30 minutes face-to-face with the patient, over half in discussion of the diagnosis and the importance of compliance with the treatment plan.”

Or

“I spent 30 minutes on the unit, over half in counseling the patient and coordinating her follow-up care after discharge.”

Avoid using time for all visits and avoid using the same time for all visits. Not all visits are 15 and 25 minutes long. Also, not all visits are dominated by counseling.

Hopefully, following this advice gets you satisfaction.

— Betsy Nicoletti, a Massachusetts-based coding and billing consultant