EM Coding Alert

Question: One of our providers wants to bill an evaluation and management (E/M) visit using time, but they want to count the time spent with the patient, as well as the time spent preparing to see the patient. Isn’t time only calculated using face-to-face time?

California Subscriber

Answer: The AMA defines time for E/M coding as the total time (based on minutes) the provider spends on the date of service during which a provider personally rendered services related to the patient’s care, even if the times are not consecutive. In other words, the time your provider spent preparing to see the patient is billable time and should be used when calculating the appropriate level of service.

This is a common misconception, and something some physicians and coders often forget, as prior to the 2021 E/M office and outpatient services updates, only face-to-face time was considered billable time.

As long as services related to a patient encounter are accounted for in the record and are performed on the same day (for example, looking through the record before the encounter and reviewing labs after the encounter), you can justify that time if an auditor questions it.