Coding office visits the easy way - based on time

An E/M office visit may be coded based solely on face-to-face time when more than half is devoted to counseling or coordination of care. CPT requirements for history, exam, and medical decision making requirements do not have to be met.

Counseling may include discussing test results, diagnostic or treatment recommendations, prognosis, risks and benefits of management options, instructions, compliance, or risk-factor reduction.

Time spent by the primary provider with the patient or the patient’s family or other primary caregiver may be counted for most visits, although Medicare stipulates that the patient be present for any E/M service that is reported for payment.

Be sure to document the total time spent and that more than half involved counseling or coordination of care, and describe the nature of the counseling or care coordination activities (e.g., “counseled patient regarding weight gain, daily food intake, and goal setting”). Choose your level of service according to CPT’s definitions of what is typical for each code.

Typical times for new patient office visits

Typical times for established patient office visits

Adapted from “Time Is on Your Side: Coding on the Basis of Time.”