What is time-based coding for E/M visits?

• A. Time-based coding uses the total time spent with the patient to determine the E/M level when counseling/coordination dominates the encounter.
• B. Time-based coding uses the number of problems addressed.
• C. Time-based coding uses documentation length alone to determine the level.
• D. Time-based coding is not used for E/M visits.

Answer: (A)

Time-based coding for E/M visits centers on how long the clinician spends with the patient and on related activities during that encounter. The CPT guidelines specify that when counseling and/or coordination of care dominates the visit, the total time spent becomes the determining factor for selecting the E/M level, rather than counting problems or the length of the notes. If extensive counseling, education, and care planning occur and the encounter lasts a significant amount of time, that time is used to determine the level of service. This approach values the effort involved in communication and coordination, which might not be reflected by the number of problems or by how long the documentation is. So, the correct concept is that time-based coding uses the total time spent with the patient to determine the E/M level when counseling/coordination dominates the encounter.