Compliance reminder: Coding based on time for physician services

The three key components of determining an evaluation and management (E/M) level are history, examination and medical decision-making. CPT descriptions include the average amount of time the physicians spend on various levels of office visits, inpatient consultations, etc. Counseling, coordination of care, nature of presenting problem and time are contributory factors when determining the E/M level.

In the case where counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

For more information on the Medicare teaching physician guidelines, contact the YNHHS Office of Privacy and Corporate Compliance, compliance@ynhh.org or 203-688-8416.