E&M Outpatient Visits and Office Consultations

Billing based on Time is an Option

Some physician/patient outpatient Evaluation and Management (E&M) visits involve a lengthy discussion of test results and continuing treatment options. These encounters may take a considerable amount of time. There is an alternative to using the three key components of history, examination and medical decision making.. If the physician spends more than half of the face-to-face time with the patient and/or the patient's family in counseling or in coordination of care, then CPT code may be selected based on the total time of the face-to-face time of the encounter.

What needs to be documented:

The encounter form (also called the "superbill") must show the total time of the encounter and the time spent in counseling or coordination of care.

The medical record must also show the total time and time spent in face to face counseling or coordination of care. PLUS the medical record must include a concise description of the content of the counseling. Just one or two lines, naming the individuals counseled and brief description of the subject matter is sufficient. It can be included in your dictation.

Be careful - that concise description in the medical record is essential. And watch out - the time requirements new and established outpatients are not the same.

More details -

Face-to-face time for these services is defined as only that time that the physician spends face-to-face with the patient/and or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient.

Counseling is a discussion with a patient and/or the family concerning one or more of following areas: diagnostic results, impressions, and /or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.

Help on a handy form.

The Office of Compliance has developed a documentation template that you may find a convenient, optional tool. It has been attached to this e-mail distribution, and can also be found on our web site under "Forms".

If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.

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