Focus on E/M services: Time

Dec. 11, 2020 / By Allison Morgan, MS, CPC

In our ongoing Evaluation and Management Services blog series, we have delved into several sweeping changes coming to Office or Other Outpatient E/M Services in 2021. Let’s shift our attention to taking a closer look at the revisions to “Time” and how it’s taking center stage in the 2021 E/M updates.

Historically for office or other outpatient visits, time only impacted visit levels when counseling and/or coordination of care dominates more than half of the visit with the patient and/or family (face-to-face time).  With this being the only option to establish time as a controlling factor for a level, its utilization was limited. While current CPT descriptors for office or other outpatient visits do include a suggested typical amount of time spent face to face with the patient during the encounter, there is some ambiguity, so they serve as reference point, not a driver of CPT selection.

2021 updates to time

Effective January 1, 2021, everything changes and time becomes a heavy hitter. As one of the two drivers for office or other outpatient CPT selection, time can now be used solely to select a level of service, regardless if counseling and/or coordination of care dominates the visit. The AMA also redefined time as “total time” and established comprehensive guidance on what total time entails.  Here are the key highlights of the changes:

  • Total time may be used to select office or other outpatient visits.
  • 99211 does not have a time associated with it and time is not a driver for code selection.
  • Assign 99211 if the providers time is spent supervising clinical staff who perform the face-to-face visit.
  • Total time includes both the face-to-face 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.
  • Total time includes the following activities
    • Preparing to see the patient
    • Obtaining separately obtained history
    • Reviewing separately obtained history
    • Performing the exam
    • Counseling and education patient/family
    • Ordering medication, tests or procedures
    • Referring and communicating with other health care professionals
    • Documenting the care
    • Independently interpreting and communicating test result to patient/family
    • Care coordination (when not separately reported)

Also, CPT will now provide the specific range of total time to support each code. The range is included in each CPT’s descriptor. A summary of the time ranges for office or other outpatient visits are below:

Documentation is still important

The updates taking place with time for office or other outpatient E/M services recognize the importance of the physician’s scope of work and streamlines level selection by providing clear guidance on time. Remember, however, that while the use of time may simplify the process of level capture for CPT, it’s important to continue to be mindful of documentation. Be clear and consistent in how you document total time. Make sure it is documented directly in the note. Include a medically appropriate history and/or exam, document what was performed, and ensure your documentation support the visit as medically necessary and reasonable.

Be on the lookout for our next blog in the E/M series which will focus on another facet of the updates.

Allison Morgan is a clinical development analyst at 3M Health Information Systems.

Learn more about the 2021 E/M changes.