Office/outpatient visit E/M time-based coding will change in 2024 to align with other E/M codes. Time ranges will be omitted and replaced with base time to meet or exceed.
The American Medical Association affirms documentation requirement for time-based coding as “….includes both the face-to-face time with the patient and/or family/caregiver 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). It includes time regardless of the location of the physician or other qualified health care professional (e.g., whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported service(s).”
Activities included in time-based documentation have not changed from 2023 and include:
- 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 healthcare professionals (when not separately reported)
- Documenting clinical information in the EHR or other health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported).
Do not count time spent on the following:
- The performance of other services that are reported separately
- Teaching that is general and not limited to discussion that is required for the management of a specific patient