Time-Based E/M Coding
In our fast-paced world, it sometimes seems there is simply not enough time in a day to get everything done. For the Maternal Fetal Medicine specialist encountering a patient whose care requires longer than the usual visit, time can seem like a “no-win” situation. There is a way to make time work to your advantage by using time-based coding for some of your patient encounters. Time-based coding may not be the primary way of selecting E/M codes, but for encounters that involve extensive counseling or pre/ post visit activities, it offers the best opportunity to get paid for your work.
The 2021 and the 2023 CPT revisions to E/M coding and documentation guidelines for time-based coding allows for an expanded use of time to determine the level of care. If time is used to select the level of service, the E/M code is based on the total amount of time on the date of service. In addition to face-to-face time, prep time and follow-up work on the same day provided personally by the MFM (or QHP) can be counted towards the selection of the E/M code. Time can be used to select codes for both outpatient and hospital-based encounters.
The physician/QHP time includes the following activities:
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically necessary and 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 reported separately)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver
- Care coordination (not reported separately)
It does not include:
- Performance of other services that are reported separately
- Travel
- Teaching that is general and not limited to discussion that is required for the management of a specific patient
- Activities provided by clinical or administrative staff
- Time spent on days other than the date of service