2021 E/M Guidelines Based on Time

Below is a listing of questions and answers regarding some of the nuances of billing Evaluation and Management office visits based on time.

The new 2021 E/M coding guidelines for office visits (99202-99205, 99212-99215) allow physicians and qualified health professionals (QHP) to choose whether their documentation and code-selection level for E/M services provided is based on medical decision making (MDM) or total time spent on the date of the patient encounter.

The definition of time was changed to total time spent on the day of the patient encounter, not typical time, and represents total physician or QHP time on the date of service. This includes the time in activities that require the physician or QHP and does not include time in activities normally performed by clinical staff. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services such as care coordination. These definitions only apply when code selection is based primarily on time and not MDM.

It’s important to note, however, that medical necessity still needs to support the amount of time spent with the patient. While some of our patients consider a doctor’s appointment as a social event, time spent in social conversation cannot be counted toward the total time of the visit.

When time is used to select the appropriate level for E/M services codes, time is defined by the code descriptors and require a face-to-face encounter with the physician or other QHP.

The time associated with each code level is:

2021 Time Calculation

• The total time of time spent should include face-to-face and non-face-to-face time working for that specific patient. 
• Only includes the time spent by the physician or QHP, not the clinical staff. 
• All time must be on the date of service, NOT the day before or the day after.
• No requirement of need to document the specific time spent in counseling and/or coordination of care. 

Time Detail

Q: What will you do if the documentation is not clear as to how the time was spent? What if just total time is noted? 

A: There is no stated policy from the American Medical Association (AMA) instructing providers to itemize time. The guidelines state that the total time and what activities were performed should be documented, including:

• Preparing to see the patient (eg, review of tests, previous progress notes of yours or another provider)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

While not everything on this list needs to be performed, what is performed needs to be listed in support of the time spent. If a clinical staff member documents part of the patient’s history, only the provider’s time spent reviewing it should be included.

For any service performed in the office that’s going to create a separate bill, the time needs to be separated out and not billed as part of the E/M service time, and this needs to be indicated in the note as well.

For those “not separately reported” services (above) to be included in the calculation of time, another provider in your same specialty cannot bill for the same service. For example, if ultrasounds are performed in your office, you cannot include in the E/M service the time you spend discussing the results with the patient because that’s being reimbursed in the ultrasound code. However, if a radiologist is being reimbursed for an x-ray interpretation and report, a primary care physician can include the time reviewing the x-ray. In other words, there is still no allowance for “double dipping.”

Other Services on Same Date

Q: 99297 (Advanced Care Planning) describes the provider spending 30 minutes in order to bill. If the provider doesn't document total time, how will you know this 99497 is appropriate to report in 2021?

A: The time for another service performed on the same day needs to be documented separately. If the service is timed, like Advanced Care Planning, the time for that service needs to be listed separately and not included in the time for the E/M code.

Documentation of Time for All Charts

Q: Should each office visit chart have total time documented starting in 2021?

A: The guidelines do not require that time be documented. My thought process is, however, that you don’t know how much time is going to be needed for any patient visit, so it would make sense to keep track of your time, in case you want to base your code level on time.

Are Telehealth Services Considered Face-to-Face?

Q: If the new E/M guidelines require face-to-face time with a provider, does this mean they can't be used for telehealth services? 

A: A telehealth service that includes video is considered face-to-face; a telephone visit is not considered face-to-face. Most payers allow video office visits to be billed with E/M codes; however, double-check with your local carriers before billing.

Shared Office Visits

Q: What if it appears two providers were seeing the patient and the time is noted as just total time?

A: A shared or split visit is defined as a visit in which a physician and other qualified healthcare professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of a service for which time-based reporting of shared or split visits is allowed, the time personally spent by a physician and a QHP assessing and managing the patient on the date of the encounter is summed to define total time.

As a best-practice recommendation, I suggest individually documenting the time spent by each provider that is distinct from the other. Here’s what I mean by that. If an MD and PA are both seeing a patient, the time for only one of the providers can be summed. Similarly, if the MD and PA are having a discussion, the time can only be counted for one of the providers. If the time for each provider isn’t separated, the time documentation could be in doubt.

Resident’s Time

Q: When a physician decides to use the time as the basis for the E/M code selection, how does it work for the resident's time? Should he include the resident's time when he documents the time, or should he exclude it?

A: Centers for Medicare and Medicaid Services teaching guidelines normally that the time for an E/M service should only include that of the teaching/billing provider.

Signature Date

Q: Does the progress note have to be signed on the date of service in order for the time element to count?

A: No. The 2021 E/M guidelines do not specify that the note needs to be signed on the date of service.

Scribe’s Time

Q: If a physician has a scribe, can the time of the scribe be counted towards the total time of choosing the level of service?

A: No, a scribe’s time is not counted. Only a physician or QHP’s time counts when calculating the total time spent on that calendar day.