Time

The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 was done to assist in selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use time differently. It is important to review the instructions for each category.

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Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-face with the patient.

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Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.

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When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.

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A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).

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When prolonged time occurs, the appropriate prolonged services code may be reported. The appropriate time should be documented in the medical record when it is used as the basis for code selection.

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Face-to-face time (outpatient consultations [99241, 99242, 99243, 99244, 99245], domiciliary, rest home, or custodial services [99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337], home services [99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350], cognitive assessment and care plan services [99483]): For coding purposes, face-to-face time for these services is defined as only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.

Unit/floor time (hospital observation services [99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236], hospital inpatient services [99221, 99222, 99223, 99231, 99232, 99233], inpatient consultations [99251, 99252, 99253, 99254, 99255], nursing facility services [99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318]): For coding purposes, time for these services is defined as unit/floor time, which includes the time present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time to establish and/or review the patient’s chart, examine the patient, write notes, and communicate with other professionals and the patient’s family.

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Total time on the date of the encounter (office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

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Physician/other qualified health care professional time includes the following activities, when performed:

preparing to see the patient (eg, 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 separately reported) ■ documenting clinical information in the electronic or other health record

■ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver

■ care coordination (not separately reported)

 

Do not count time spent on the following:

■ the performance of other services that are reported separately

■ travel

■ teaching that is general and not limited to discussion that is required for the management of a specific patient

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Concurrent Care and Transfer of Care

Concurrent care is the provision of similar services (eg, hospital visits) to the same patient by more than one physician or other qualified health care professional on the same day. When concurrent care is provided, no special reporting is required. Transfer of care is the process whereby a physician or other qualified health care professional who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician or other qualified health care professional who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician or other qualified health care professional transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician or other qualified health care professional who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service.

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Counseling

Counseling is a discussion with a patient and/or family concerning one or more of the following areas:

■ Diagnostic results, impressions, and/or recommended diagnostic studies

■ Prognosis

■ Risks and benefits of management (treatment) options

■ Instructions for management (treatment) and/or follow-up

■ Importance of compliance with chosen management (treatment) options

■ Risk factor reduction

■ Patient and family education

(For psychotherapy, see 90832-90834, 90836-90840)

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Services Reported Separately

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Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately.

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The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of MDM.

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The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

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Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home E/M Services

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Levels of E/M Services

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The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are:

■ History

■ Examination

■ Medical decision making

■ Counseling

■ Coordination of care

■ Nature of presenting problem

■ Time

The first three of these components (history, examination, and medical decision making) are considered the key components in selecting a level of E/M services. (See “Determine the Extent of History Obtained.”)

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The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters. Although the first two of these contributory factors are important E/M services, it is not required that these services be provided at every patient encounter.

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Coordination of care with other physicians, other health care professionals, or agencies without a patient encounter on that day is reported using the case management codes. The final component, time, is discussed in detail following the Decision Tree for New vs Established Patients.

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Chief Complaint

A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.

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History of Present Illness

A chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s).

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Nature of Presenting Problem

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A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows:

 

Minimal: A problem that may not require the presence of the physician or other qualified health care professional, but service is provided under the physician’s or other qualified health care professional’s supervision.

 

Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

 

Low severity: A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.

 

Moderate severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.

 

High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

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Past History

A review of the patient’s past experiences with illnesses, injuries, and treatments that includes significant information about:

■ Prior major illnesses and injuries

■ Prior operations

■ Prior hospitalizations

■ Current medications

■ Allergies (eg, drug, food)

■ Age appropriate immunization status

■ Age appropriate feeding/dietary status

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Family History

A review of medical events in the patient’s family that includes significant information about:

■ The health status or cause of death of parents, siblings, and children

■ Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review

■ Diseases of family members that may be hereditary or place the patient at risk

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Social History

An age appropriate review of past and current activities that includes significant information about:

■ Marital status and/or living arrangements

■ Current employment

■ Occupational history

■ Military history

■ Use of drugs, alcohol, and tobacco

■ Level of education

■ Sexual history

■ Other relevant social factors

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System Review (Review of Systems)

An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. For the purposes of the CPT codebook the following elements of a system review have been identified:

■ Constitutional symptoms (fever, weight loss, etc)

■ Eyes

■ Ears, nose, mouth, throat

■ Cardiovascular

■ Respiratory

■ Gastrointestinal

■ Genitourinary

■ Musculoskeletal

■ Integumentary (skin and/or breast)

■ Neurological

■ Psychiatric

■ Endocrine

■ Hematologic/lymphatic

■ Allergic/immunologic

 

The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options.

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Instructions for Selecting a Level of E/M Service for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home E/M Services

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Review the Level of E/M Service Descriptors and Examples in the Selected Category or Subcategory

 

The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are:

■ History

■ Examination

■ Medical decision making

■ Counseling

■ Coordination of care

■ Nature of presenting problem

■ Time

 

The first three of these components (ie, history, examination, and medical decision making) should be considered the key components in selecting the level of E/M services. An exception to this rule is in the case of visits that consist predominantly of counseling or coordination of care.

 

The nature of the presenting problem and time are provided in some levels to assist the physician in determining the appropriate level of E/M service.

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Determine the Extent of History Obtained

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The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of history that are defined as follows:

 

Problem focused: Chief complaint; brief history of present illness or problem.

 

Expanded problem focused: Chief complaint; brief history of present illness; problem pertinent system review.

 

Detailed: Chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social history directly related to the patient’s problems.

 

Comprehensive: Chief complaint; extended history of present illness; review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family, and social history. The comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief complaint or present illness. It does, however, include a comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.

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Determine the Extent of Examination Performed

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The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of examination that are defined as follows:

 

Problem focused: A limited examination of the affected body area or organ system.

 

Expanded problem focused: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

 

Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ system(s).

 

Comprehensive: A general multisystem examination or a complete examination of a single organ system. Note: The comprehensive examination performed as part of the preventive medicine E/M service is multisystem, but its extent is based on age and risk factors identified.

 

For the purposes of these CPT definitions, the following body areas are recognized:

■ Head, including the face

■ Neck

■ Chest, including breasts and axilla

■ Abdomen

■ Genitalia, groin, buttocks

■ Back

■ Each extremity

 

For the purposes of these CPT definitions, the following organ systems are recognized:

■ Eyes

■ Ears, nose, mouth, and throat

■ Cardiovascular

■ Respiratory

■ Gastrointestinal

■ Genitourinary

■ Musculoskeletal

■ Skin

■ Neurologic

■ Psychiatric

■ Hematologic/lymphatic/immunologic

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Determine the Complexity of Medical Decision Making

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Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

■ The number of possible diagnoses and/or the number of management options that must be considered

■ The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed

■ The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options

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Four types of medical decision making are recognized: straightforward, low complexity, moderate complexity, and high complexity. To qualify for a given type of decision making, two of the three elements in Table 1 must be met or exceeded.

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Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making.

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