OFFICE OR OUTPATIENT EVALUATION AND MANAGEMENT (E/M) SERVICES
For Time-Based E&M, Whose Time Can be Counted?
As of January 1, 2021, the levels of office or outpatient services are now calculated by medical decision making or total visit time. This article is focused on when time is used to determine the level of service as well as provide clarity on whose time can be counted.
WHOSE TIME COUNTS?
To begin, it is important to first understand how the AMA CPT Codebook makes the distinction between a qualified health care professional vs. a clinical staff member. In the Instructions for Use of the CPT Codebook, they are defined as:
- [i]Qualified health care professional: Is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.
- Clinical staff member: Is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.
Qualified health care professionals are distinct from clinical staff members. In fact, the Evaluation and Management (E/M) Services Guidelines under Time, instructions are explicit:
- “For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).”
In summary, only physicians and/or other qualified health professionals can count their time to determine the level of E/M services. Clinical staff members time cannot be counted.
WHAT ACTIVITIES COUNT?
Per CPT E/M Guidelines: “Physicians/other qualified health care professional time includes the following activities when performed:
- preparing to see the patient (e.g., review of tests)
- obtaining and/or reviewing separately obtained history
- performing a medically 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 separately reported)
- documenting clinical information in the electronic or other health record
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- care coordination (not separately reported)”
When using time to determine the level of E/M service it is important to know whose time counts.
- Physicians and qualified health care professionals time is counted to determine the total time because they are billing providers.
- The time spent by clinical staff members cannot be counted to determine the total time.
CPT 2021 Professional Edition, Instructions for Use of the CPT Code book and Evaluation and Management (E/M) Services Guidelines – Time
[i] Physicians are also defined the same way.