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Jenny Harvey, RHIT, CPHQ, CPC, CPMA, AHIMA Approved ICD-10-CM/PCS Trainer
LBMC Advisory Services Manager
Healthcare Consulting

The American Medical Association (AMA) released new guidelines on January 1, 2023. CPT® published new rules for using time to select a level of Evaluation and Management (E/M) service. Now, these rules apply equally to services performed in the office, the hospital, or nursing facility. This seems simple, right? Review the time documented in the medical record and assign the corresponding E/M code.

Time-based coding for outpatient E/M services can be challenging, but with proper documentation, it can be easily managed. Medical necessity requirements are still non-negotiable.

Supporting documentation must be present to substantiate the medical necessity for the E/M service. These documents should provide detailed and specific information to justify the time spent during the encounter. Total time includes both in-person and remote activities performed by the provider on the day of the encounter.

Activities that count as E/M time

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically 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)

Do not count time spent on the following:

• The patient was seen on a calendar day other than the day they spent time
• Other separately reported services, such as procedures, AWV, chronic care management, and transitional care management
• Travel
• Clinical staff time (activities performed by medical assistants, nurses)
• Time spent on general teaching that is not limited to discussion required for the management of a specific patient

Pitfalls Ahead

• Don’t double count total time spent on the E/M service if it’s already been separately reported. Time must be exclusive to the E/M service only.
• Extra reported service time must be subtracted from total E/M time and be documented accordingly.

Remember, an E/M time attestation carries the same penalties for false reporting as anything else in the claim. Use it judiciously and record it accurately.

Accurate documentation and following medical necessities are important in healthcare services. This is especially true under the new AMA and CPT® guidelines for time-based coding. Careful consideration of activities, avoidance of pitfalls like double-counting, and accurate recording are essential for compliance. For expert guidance in navigating these guidelines, LBMC’s Healthcare Consulting team is ready to assist you.