Time: using time for E/M services in 2021

• The American Medical Association (AMA) revised codes 99202—99215 in 2021. These changes are in the 2021 CPT book.
• Beginning in 2021, time alone can be used to select one of these codes, whether or not counseling dominates the visit. Non-face-to-face activities performed by the billing clinician on the day of the E/M service may be included in the time.
• There will be different rules for using time for different categories of E/M services.

New and established patient office visits.

For codes 99202—99215, time may be used to select the code whether or not counseling and or coordination of care dominates the service. There is no change to the time rule for other E/M services in 2021. The rules for inpatient services, observation, ED visits, consultations, home visits, domiciliary care visits and nursing home visits continue to use the 1995/1997 guidelines. Using time when billing for codes 99202—99215 requires a face-to-face service by the physician, advanced practice registered nurse (APRN), or physician assistant (PA).

New time rules for office services

The new CPT^® rules allow all of these services, listed below, to be included in the total practitioner time, used to select a CPT^® code.

Physician/other qualified health care professional time includes the following activities, when performed:

• preparing to see the patient (eg, review of tests)
• 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 (when 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)

Count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.

Describe what was done, and document time in a single statement. “I spent 30 minutes reviewing the patient’s diagnostic tests, seeing the patient, talking with the visiting nurse, and documenting in the record.” It isn’t necessary to note how much time was spent in each activity.

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