E&M Coding Based on Time

Question:

Our physicians’ default to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform procedures such as nasal endoscopy, sinus debridement, laryngoscopy, etc. in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent. That said, the activities you identify are billable services represented by other CPT codes (aka are separately reported) and may not contribute to the total time in the billed Evaluation and Management (E/M). In other words, the procedure time must be deducted from the total time, assuming the E/M service is reportable.

*This response is based on the best information available as of 10/19/23.