CPT 2008 will add reference times to several E/M code categories that did not previously include them -- specifically nursing facility care (99304-99310) and annual nursing assessments (99318). Although general surgeons are unlikely to provide these services, the addition of a reference time means that, when necessary and supported by documentation, you may select an E/M service level using time (rather than the key components of history, exam and medical decision-making) as the primary deciding factor.