There are instances when it is more appropriate to base an evaluation and management (E/M) service on time rather than other key components such as history, examination, and medical decision-making. Proper documentation supporting the decision to base the encounter on time is paramount, however.

In the Medicare Claims Processing Manual, 100-04, chapter 12, section 30.6.1(c), the Centers for Medicare & Medicaid Services (CMS) provides an example of when time spent in counseling/coordination of care and medical decision-making would determine the level of service billed:

EXAMPLE: A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit, the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing.

Although the physician need not complete a history and physical examination in order to select the level of service, documentation must include:

  • The time the physician spent on counseling/coordination of care: The duration may be documented as total time or a statement that identifies that more than half the time was counseling/coordination of care (e.g., greater than 50 percent of my time was spent on counseling/coordination of care).
  • Duration of the visit: This can be the total time or time in and out.
  • A description of the counseling/coordination of care provided.

Tip: Base the code selection on the total time of the face-to-face encounter or floor time, not just the counseling time. The duration of counseling or coordination of care that is provided face-to-face, or on the floor, may be estimated but that estimate, along with the total duration of the visit, must be recorded.

The key word here is “face-to-face.” In the office and other outpatient setting, you can count only counseling and/or coordination of care provided by the physician in the presence of the patient. Counseling and/or coordination of care provided by ancillary staff cannot be considered toward time or level of service. Ultimately, the code depends on the service provided by the physician.

“Face-to-face” has a broader definition in an inpatient setting. The physician needs only to be on the same hospital floor or unit that is associated with the patient. However, once the physician begins to care for another patient on the floor, the clock stops.

Resource:  For more information, see the Medicare Claims Processing Manual, 100-04, chapter 12, section 30.6.1(c) at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.