When to use time to select an office visit code using the 2021 E/M guidelines

• Select the level of service for codes 99202—99215 based on time or medical decision making (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
• The practitioner does not need to meet both MDM and time

The CPT® rules for using time to select an office visit changed at the beginning of January 2021. 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. Now, document total 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)

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