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 a 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 for 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.

New Patient Visit Time	Established Patient Visit Time	Office Consultation Time
99201 10 minutes	99211 5 minutes	99241 15 minutes
99202 20 minutes	99212 10 minutes	99242 30 minutes
99203 30 minutes	99213 15 minutes	99243 40 minutes
99204 45 minutes	99214 25 minutes	99244 60 minutes
99205 60 minutes	99215 40 minutes	99245 80 minutes
Initial Hospital Care Time	Subsequent Hospital Care Time	Inpatient Consultation Time
99221 30 minutes	99231 15 minutes	99251 20 minutes
99222 50 minutes	99232 25 minutes	99252 40 minutes
99223 70 minutes	99233 35 minutes	99253 55 minutes
		99254 80 minutes
		99255 110 minutes

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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Webmaster<athagan@ufl.edu>College of Medicine, Office of Compliance  This page created October 21, 1999.  Modified 2/24/2011 Please read our disclaimer and permitted use statement.