Time Statements for E/M Visits: What Coders and Providers Need to Know

Nicoletti Notes January 2026
Published on January 13th, 2026

Time-based coding for Evaluation and Management (E/M) services can be a powerful tool, but only when used correctly. Incomplete or vague documentation of time can lead to denials, audits, and compliance issues. Here’s a breakdown of the best and worst practices when documenting time for E/M visits.

Time Statements: What to Avoid

Too Short: “Time Spent” with No Details
Simply stating “30 minutes spent with patient” isn’t enough. Without a description of the work performed, it’s most certainly impossible to justify the level of service.

Why It Fails: Payers need to see what was done during the time stated (e.g., history review, time with the patient, counseling, coordination of care after the visit, documentation, etc).

Too Vague: Greater Than or Less Than
Statements like “>30 minutes” or “less than 15 minutes” are ambiguous and lack clarity.
These phrases don’t align with CPT® guidelines, and they do not support precise code selection.

Why It Fails: Coding requires specific time ranges and vague estimates do not meet CPT® documentation standards.  Internal and external auditors won’t credit these.

Teaching Physician Time Not Clearly Documented
When residents or fellows are involved in direct patient care, the attending physician’s time spent in direct patient care versus time spent in teaching the resident or fellow must be clearly documented. Statements like “I personally spent 40 minutes outside of teaching time with the patient discussing treatment, reviewing records, and documenting in the chart”, make it clear that only direct patient care time was used in calculating the level of service.

Why It Fails: Only the time the teaching physician spends outside of teaching activities counts toward E/M coding. CMS requires clear delineation, and most major commercial carriers follow CMS guidelines as well.

Best Time Statements: What to Include

Specific Time + Description of Activities
“I spent a total of 35 minutes discussing the patient’s new diagnosis of diabetes, medication options, and lifestyle changes.”

Clear Separation of Teaching Time
“Total time spent: 40 minutes. Of this, 25 minutes were direct patient care by the attending physician, excluding time spent teaching the resident.”

Time Range Matching CPT® Guidelines
“Total time: 60 minutes, used for reviewing labs, discussing treatment options, and coordinating care with the patient’s cardiologist.”

Specific time documentation supports accurate coding, protects against potential paybacks, and ensures fair reimbursement. A great rule of thumb is to be specific, clear, and always tie documentation of time back to the work performed.