Although there are seven components for the levels of evaluation and management (E/M) services, most encounter levels are coded on the basis of the history, examination and medical decision making (MDM), which are the key components extracted from documentation in the medical record. However, when counseling and coordination of care for a patient are the predominate activities in the visit, time is the component that can be used to appropriately capture the level of E/M service.
In 1992, time was included as an explicit factor for several categories of E/M services, including office visits, consultations and inpatient services. The time associated with these codes in the CPT Evaluation and Management Service guidelines is considered the average time spent providing a particular level of care to a patient (see Table 1, below, for time codes for outpatient services). To determine when to use time as the key or controlling factor, providers and their coding staff should refer to the specific details outlined in the CPT Evaluation and Management Service guidelines:
- Counseling and/or coordination of care dominates (more than 50%) the patient encounter;
- The E/M service must have a reference time identified in the code descriptor;
- Time must be spent face to face with the patient and/or family member in the office/other outpatient setting or floor/unit time in the hospital or nursing facility; and
- The extent of the counseling and/or coordination of care must be documented in the medical record.
This means that time alone can be used to select a level of care, regardless of the extent of the history, exam or MDM, if the majority of the encounter involves counseling or coordination of care. For E/M services, counseling may include a discussion of test results, diagnostic or treatment recommendations, prognosis, risks and benefits of management options, instructions, education, compliance and/or risk factor reduction.
But be careful, because it is important to remember criteria are attached to the time component as much as to the history, examination and MDM. Keep in mind when selecting a level of service on the basis of the extent of the history, examination or MDM, sufficient details must be included in the medical record to apply the most accurate level. For example, the provider cannot simply document, “I performed a comprehensive history.” Instead, the provider must document detailed information that is relevant to the patient’s history of present illness, the number of systems reviewed, and past, family and social history. Also, the MDM is not based on a single statement, but is calculated on the basis of the number and type of details documented for each component. The same rationale holds true when using time as the main factor for coding the encounter.