Clinical Staff Time

Question: I believe that I know the answer to this question but am hoping you know the source, as I can’t find it—if a nurse helps with ROS, medication reconciliation, etc., would their time (if documented) be able to be included in the time for the visit?

Answer: No. The answer to this question is in the CPT^® book, in the E/M section, page 13 of the 2024 book. In a discussion of total time for office visits it says

“For coding purposes, time for the services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time 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 healthcare professional and does not include time in activities normally performed by clinical staff).

Later on that page, it says that the time of the physician/other qualified health care professional can include reviewing separately obtained history. But the time of the clinical staff member who obtains that history may not be included.

See also When to use time to select an E/M service.