• Selecting a code for an E/M service can be done based on time or MDM (except ED visits which only use MDM)
• Time includes all time spent by the billing practitioner on the date of service, not just face-to-face time, and counseling does not need to dominate the visit, as it did in the 1995/1997 guidelines
• The practitioner does not need to meet both MDM and time
• This article discusses when to use time to select a level of E/M service

The CPT® rules for using time to select a level of E/M service are now the same, whether done in the office, the hospital or nursing facility.  A practitioner may use total time on the date of service, and counseling doesn’t need to be more than 50% of the face-to-face time. If you haven’t changed your templates that read, “I spent 30 minutes face-to-face with the patient, more than half of which was in counseling and coordination of care,” do that now. Document total time spent and what was done. (Examples later in article.)  Avoid all time statements that use the exact code time.

CPT® rules

The new CPT® rules allow all of these activities, listed below, to be included in the total time, used to select a CPT® code. Do not count staff time in performing these activities.

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)