Code level selection is now simplified — based on either medical decision making or total time. The authors' one-page coding reference tool can help simplify the new rules.

There are many other evaluation and management services in which the coding is based specific time parameters. The code description will include instructions such as “first x minutes”, “up to” “x minutes …

When a CPT code is defined by time, the clinician must document time in the medical record. Examples of this are some psychiatry codes, certain physical therapy modalities, critical care, the second level …

Time Spent: 40 minutes face-to-face with the patient. Threshold: For CPT code 99215, the total time spent must meet or exceed 40 minutes on the encounter date. Key Activities: Reviewing history, …

Jul 14, 2024 · Allows clinicians to choose the E/M visit level based on medical decision making OR time (and CBO interpretation). • 8 elements: Location, Severity, Timing, Duration, Quality, Context, …

As of Jan. 1, 2023, the coding and documentation guidelines for level-based E/M encounters, including hospital inpatient and observation visits, consults, and services in the emergency department, …

Each unique test, order, or document contributes to a combination of 2 or of 3 in Category 1 below. For independent interpretation and discussion of management or test interpretation, see Level 4 or 5.

ed coding: Ensure the total time was documented. Use the far-right column of the tool to determine the visit level and corresponding CP code based on the number of minutes docume

Use the E/M Calculator from the experts at Codify. Check CMS Documentation Guidelines, Time-Based Coding, and get on the fast track to E/M level accuracy.

Jul 25, 2025 · Get real answers from the AMA to common myths about documenting the time spent on each specific task associated with an outpatient visit.