E/M Coding Guidelines Based On TIME

The Evaluation and Management (E/M) coding guidelines based on time refer to the amount of time a healthcare provider spends with a patient during a visit. These guidelines apply to office or outpatient visits and can be used to determine the appropriate level of E/M code to bill for the visit.

The time-based E/M coding guidelines are as follows:

1. Time must be documented in the medical record for each encounter.
2. The time spent with the patient must be face-to-face time, meaning the provider must be in the room with the patient.
3. The time spent with the patient must be spent on medically necessary and reasonable services.
4. The time spent with the patient must be continuous, meaning there should be no interruptions.
5. The provider must document the start and end times of the encounter.
6. The provider must document the total time spent with the patient.
7. The provider must document the specific activities performed during the visit.
8. The provider must meet or exceed the minimum time requirements for the specific E/M code being billed.

It’s important to note that time is not the only factor in determining the appropriate E/M code. The level of complexity and the nature of the medical decision-making also play a role. Providers must consider all relevant factors when determining the appropriate E/M code to bill for a visit.