What are the guidelines/rules for billing an E/M service based upon total time?
• For coding purposes, time for these services is the total time on the date of the encounter.
○ It includes both the face-to-face time with the patient and/or family/caregiver 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 health care professional and does not include time in activities normally performed by clinical staff)
○ It includes time regardless of the location of the physician or other qualified health care professional (eg, whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported service(s).
• Physician or 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)
• Do not count time spent on the following:
1. The performance of other services that are reported separately
The medical record needs to document specifically how the total time was used for all of the items that were performed above under “Physician or other qualified health care professional time includes the following activities, when performed.”
How should time be documented?
• Example - Document: “I spent xx minutes seeing the patient, xx minutes coordinating care with the physical therapist at the physical therapy facility and xx minutes documenting in the medical record.”
This is my opinion.
Michael G. Warshaw
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