Coding Based on Time

The level of care for any encounter (except emergency department E/M services) may be selected based on time or based on the MDM required for the visit.

If you choose to code based on time, it is important to understand the rules for adding up time spent.

Total time typically includes the time spent before, during and after the visit on the date of the encounter.

For example, suppose you see an established office patient who requires moderate complexity MDM.  You spend ten minutes reviewing the chart before the patient arrives, twenty minutes with the patient and ten minutes after the visit transmitting prescriptions or documenting the visit.  This would add up to a total of forty minutes.

Looking at the requirements for established office visits below, this means you would qualify for the 99215 level of care, even though the encounter only required moderate complexity MDM.

For most encounters, the rules for adding up time spent are fairly straightforward, but for others, the rules can be more complex.  Some visits even allow you to include time spent days before and even days after the visit. 

Each of our courses will outline the specific rules for time-based coding for the encounters being discussed, so you will always get credit for the time you spend caring for your patients.