Accurate documentation of the time spent with a patient is now a primary method for determining the appropriate level of service for billing and reimbursement. The shift in documentation rules allows providers to select an Evaluation and Management (E/M) code based on either the complexity of the Medical Decision Making (MDM) or the total time spent on the date of the encounter. This flexibility is paired with a high standard of compliance, making precise documentation of time crucial for all healthcare providers, coders, and billing staff to ensure audit readiness and proper payment.
Defining Billable Time for Documentation
Billable time, often referred to as “total time,” includes both face-to-face time with the patient and non-face-to-face work performed by the physician or Qualified Healthcare Professional (QHP) on the same calendar day as the encounter. This total time encompasses various activities related to the patient’s care. Activities that count include preparing to see the patient (such as reviewing tests or prior records), independently interpreting results that are not separately reported, and ordering medications or procedures.
Counseling and educating the patient, their family, or caregiver, as well as communicating with other healthcare professionals about the patient’s care (when not separately reported), are also included. The time counted must be the personal time of the physician or QHP; time spent by clinical staff, such as medical assistants or licensed practical nurses, does not count toward the total E/M time. Activities like travel time or general teaching not specific to the patient’s management are excluded from the total time calculation.
Scenarios Where Time Controls Code Selection
Time serves as the controlling factor for code selection across several major categories of Evaluation and Management (E/M) services. The most common category where this applies is office or other outpatient visits, which correspond to CPT codes 99202 through 99215.
The option to use time for code selection also extends to other settings, including hospital inpatient and observation care services, emergency department visits, and consultations. When using time, the provider must meet or exceed a specific minimum time threshold assigned to each code level. For instance, a level 4 established patient visit (99214) requires the total time on the date of the encounter to meet or exceed 30 minutes.
Required Components of the Time-Based Note
When time is used to select the code level, the medical record must include specific mandatory elements to support the billing. Documentation must clearly state the total time personally spent by the physician or QHP on the date of the encounter. While explicit start and end times are not universally required, stating the definitive total time is a necessary component for compliance.
Beyond the total duration, the note must contain a brief but descriptive summary of the activities performed during that time. This summary should connect the time spent to the complexity of the service provided, helping an auditor understand the medical necessity for the duration of the visit. For example, the note might state, “40 minutes were spent reviewing new patient records, counseling on a new diagnosis of diabetes, and coordinating follow-up with a nutritionist.” This detail prevents questioning the extended duration of the service.
Documenting Prolonged Services
Prolonged services are reported when the total time spent exceeds the highest level of care in the E/M code series, specifically codes 99205 (new patient) or 99215 (established patient). To report a prolonged service, the provider must first meet the minimum time threshold for the highest-level E/M code. Only the time spent beyond that threshold can be counted toward the prolonged service.
The specific code used for prolonged services depends on the payer. For Medicare patients, HCPCS code G2212 is used for each additional 15 minutes of service after the level 5 threshold has been exceeded. For commercial and other non-Medicare payers, CPT code 99417 is used for each additional 15 minutes of prolonged time. Documentation must clearly show the time increment has been met before the add-on code can be billed.