Using Time to determine an Outpatient E/M code

Our goal in this blog series is to encourage conversation regarding open topics in the 2021 E/M Guidelines. We’re hoping to help bring clarity, to provide scenarios for your consideration, and to help you educate your providers.

The previous E/M Guidelines stated that Time may only be used when counseling and/or coordination of care dominates the service.

As of January 1, 2021, the AMA has provided new definitions on using Time to determine an E/M code. 

The 2021 AMA CPT(R) Manual states: 

“For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face tie personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).”

The exception is 99211. Per the AMA, “the time component has been removed” for 99211. The time to supervise clinical staff is not measured. The CPT(R) Manual states “… if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.”

Although using Time to code an E/M would seem to be a welcomed change, industry thought leaders are asking “how will practices justify the E/M code billed based on Time when medical necessity is the “overarching criterion” for coding an E/M service?”

Here are the conditions outlined in the 2021 CPT(R) Manual. Bold font is our device to call attention to specific definitions. 

Expanded definition

  • includes both the face-to-face and non-face to-face time

Specific timing

  • on the day of the encounter

Specific qualifications

  • personally spent by the physician and/or other qualified health care professional(s)
  • (includes time in activities that require the physician or other qualified health care professional
  • and does not include time in activities normally performed by clinical staff ).

AMA’s 2021 CPT(R) Manual lists nine activities that can be included in defining the Total Time spent in caring for a patient. Note that these activities cover pre-encounter, intra-encounter, and post-encounter activities.

As our audit experts recommend, remember to document the medical necessity for the encounter. Also, remember that Total Time for the provider’s day should be reasonable. If an auditor were to add up all the time billed, would the total time for the day be physically possible? As we’ve noted in a prior post, auditors are looking for “potential fraud, such as claims development and submission processes, code gaming … “

In your education and planning for coding Outpatient EMs for dates of service in 2021, under what scenarios will you use Time to bill an Outpatient E/M code?

What documentation will you train your providers to do to communicate the medical necessity?

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