Overview
E&M Services may be selected based on either medical decision-making (MDM) or total time spent on the date of service. Total time includes both face-to-face and qualifying non-face-to-face activities performed by the billing provider.
Critical Documentation Rules
- Time must be accurately documented in the note to ensure proper utilization of time-based billing.
- Do not use “greater than” time (e.g., “>55 minutes spent”). Correct format: “Total time spent on the date of the encounter: 55 minutes.”
Copy/Paste Documentation Policy
- Time must be updated for every single encounter.
- Providers must remove copied-forward time statements and re-enter the actual time for that day.
- If the time is not updated, we cannot bill based on time. Coding will default to MDM.
What Counts Toward Total Time
- All face-to-face and non-face-to-face time personally spent on the day of the visit
- Preparing (e.g., review of tests)
- Discussion with trainees, including teaching, specifically about the patient’s case
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate exam and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests or procedures
- Referring and communicating with other health care professionals (not separately reported)
- Documenting clinical information in electronic or other health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
What Does NOT Count
- Staff-only time without provider involvement
- Trainee time
- Separately reportable services (procedures, test interpretations)
- Time unrelated to direct patient care (admin work, resident teaching not tied to patient)
Documentation Best Practice
- Utilize the compliance-approved Smart Phrase: “.TIMESPENTDOS”
- Explicitly state the total time spent on the date of the encounter
- List qualifying activities
- Avoid vague language
- Avoid approximate language (e.g., “I spent approximately 50 minutes”)
Why This Matters
- Protects against audit risk from cloned/copy-paste time.
- Supports accurate E/M level selection when time exceeds MDM
- Ensures provider effort in complex cases is recognized and compliant.
