Awareness : OBC Tips

Using TIME as a Determining Factor to Code a Visit

Time shall be considered for coding an E/M in lieu of H-E-MDM when > 50% of the total billable practitioner visit time is counseling/coordination of care (CCC.)

Time is only Face-to-face for OP setting

  • Coding based on time is generally the exception for coding.
  • It is typically used:
  • Significant exacerbation or change in the patient’s condition,
  • Non-compliance with the treatment/plan,
  • Counseling regarding previously performed procedures or tests to determine future treatment options, or
  • Behavior/school issues.

Required Documentation For Billing:

  • Total time of the encounter excluding any separate procedure, if performed, and
  • That more than 50% of the total time spent was counseling and/or coordinating care


“I spent ____ minutes with the patient and family and over 50% was in counseling about her diagnosis, treatment options including _______ and ______.”

“I spent ____ minutes with the patient and family more than half of the time was spent discussing the reisks and benefits of treatment with… (list risks and benefits and specific treatment)”

“This entire ____ minute visit I spent counseling the patient regarding _______ and addressing their multiple questions.”

The entire time to prep, perform and communicate results of a billable procedure to a patient must be carved out of the E/M encounter time.

Documentation must reflect the specific issues discussed with patient present. Document the specific topics that were discussed during the counseling (i.e. diagnosis, prognosis, treatment options, medical management and side effects, etc).