Time-Based Evaluation and Management

AAPC

COC, CPC, CPC-P, CANPC, CCC, CCPC, CCVTC, CDEI, CDEO, CEDC, CEMC, CENTC, CFPC, CGIC, CGSC, CHONC, CIC, CIMC, COBGC, COPC, COSC, CPB, CPCD, CPCO, CPEDC, CPMA, CPMS, CPPM, CPRC, CRC, CRHC, CSFAC, CUC

AHIMA

CCA, CCS, CCS-P, RHIT, RHIA, CDIP, CHDA, CHPS

For Time-Based E/M Services, total time calculation includes a variety of activities conducted by the physician or other qualified health care professional. These activities include preparing to see the patient by reviewing tests, obtaining or reviewing separately obtained history, performing a medically appropriate examination and/or evaluation, counseling and educating the patient/family/caregiver, documenting clinical information in the health record, independently interpreting results and communicating them to the patient/family/caregiver, and care coordination (if not separately reported). For the time to count towards the E/M code, these activities must be documented and performed on the date of service of the encounter.

In shared visits, when a physician and one or more other qualified healthcare professionals perform work, the time can be summed up, but it cannot be concurrent or double-counted. Only time spent separately by providers can be combined for billing. Shared visits are applicable in certain settings like hospital outpatient departments (POS 22). For teaching physicians, the time counted towards a claim must be the time the teaching physician was present. Time spent by the resident without the teaching physician’s presence cannot be added to the teaching physician’s time with the beneficiary. Different service codes have specified considerations for the applicability of time-based E/M Services, ensuring accuracy and avoiding improper payments.