The American Medical Association (AMA) has released a summary regarding the 2021 changes in documenting the time for specific tasks for Evaluation and Management (E/M) office and other outpatient visits. A myth persists that Physicians and other qualified health professionals are required to document the time spent on each specific task associated with an outpatient visit even if they are not billing by time.
As most are aware by now, the 2021 revisions to the E/M office visit coding documentation requirements no longer include the documented history and physical exam in determining the appropriate level of service. Physicians now have the choice to bill office/outpatient E/M encounters solely based on medical decision making (MDM) or the total time spent on the date of that encounter. The time spent on the encounter includes both face-to-face and non-face-to-face time personally spent by the physician (and/or other qualified health care professional) and may include several activities.
If time is to be used to calculate the E/M code rather than MDM, physicians should include the total amount of time they spent associated with that visit on the date of service, which in addition to face-to-face time in the exam room or in a telehealth encounter, can also include prep time and follow-up work on that same date. These activities can include:
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically necessary appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other health care professionals (when not reported separately)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver
- Care coordination (not reported separately)
The AMA reminds physicians that that there is no requirement to document the total time spent if the physician is not using time to calculate the level of service.