Total time on the date of the encounter may be used instead of MDM for office/outpatient E/M code selection. Time has been redefined from "typical face-to-face time" to the sum of both face-to-face and non-face-to-face services of the physician or QHP on the date of the encounter. In addition, time may be used to select a code level for office/outpatient E/M services whether or not counseling and/or coordination of care dominates the service.
The tables below highlight the changes in time reporting requirements for office/outpatient E/M codes.
Examples of Using Time for Code Selection Beginning in 2021
The following clinical scenarios provide examples of using time for reporting an office visit for an established patient with a new 2-centimeter lump on the lower back
Scenario A: On the day of the visit, Dr. Smith spends 5 minutes reviewing a patient's chart while clinical staff gowns the patient and takes vitals. Dr. Smith then spends 15 minutes updating the patient's history and performing a brief examination of the patient's back. Based on a review of the chart and the H&P, Dr. Smith determines the lump is a lipoma that does not require treatment. After the patient leaves the office, Dr. Smith completes the notes about the visit in the patient's chart. Dr. Smith spent a total of 25 minutes in face-to-face and non-face-to-face E/M services related to this patient encounter on the day of the visit. If time were used for code selection, Dr. Smith would report CPT code 99213 (i.e., 20-29 minutes total time), even though the presenting problem was minor and required no treatment.
Scenario B: On the day of the visit, Dr. Smith spends 5 minutes reviewing a patient's chart while clinical staff gowns the patient and takes vitals. In this scenario, the patient is obese and has limited mobility. It takes Dr. Smith a few extra minutes to position the patient for an examination of the lower back and then reposition him to sitting. The patient also has limited English proficiency and his son who came with the patient helps with translation. This results in Dr. Smith spending 20 minutes face-to-face with the patient. Based on a review of the chart and the H&P, Dr. Smith determines the lump is a lipoma that does not require treatment. After the patient leaves the office, Dr. Smith completes the notes about the visit in the patient's chart. In this scenario, Dr. Smith spent a total of 30 minutes in face-to-face and non-face-to-face E/M services related to this patient encounter on the day of the visit. If time were used for code selection, Dr. Smith would report CPT code 99214 (i.e., 30-39 minutes total time), even though the presenting problem was minor and required no treatment.
Download the Office E/M Coding Changes Guide (PDF)
