Time Reporting for E/M Levels

Question:

My physician is billing office visits 99202-99215 based on time only.  Is this best practice?

Answer:

The E/M services 99202-99205 are based on either medical decision making or time..  Practitioners may choose to either bill by time or medical decision making.  The practitioner should evaluate each patient encounter to determine which method is more advantageous.  If time is used to calculate the E/M service, the total time should include all work associated with the patient encounter on the date of service.  KZA recommends that the practitioner document an attestation statement itemizing the time spent on the specific activities for the patient.  Example:. “This encounter took 45 minutes of time including taking a history, performing the examination, reviewing the CT scan, reviewing the PCP’s notes, counseling the patient on the conditions treated formulating a plan of care as well as documenting in the EHR.”

*This response is based on the best information available as of 12/14/23.