When is time a factor in determining the coding level of the usual evaluation and management services (new and established patient office visits, consultations and hospital follow-ups)?
When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter, then time, rather than elements of history, physical examination and medical decision-making, is the key controlling factor in the level of evaluation and management service determination. The definition of each evaluation and management code lists its typical time. The total length of time of the encounter should be documented and the medical record should describe the counseling and/or activities to coordinate care. The definition of “time” differs in outpatient and inpatient settings: face-to-face time: office and other outpatient visits and office consultations, unit/floor time: hospital observation services, inpatient hospital care, initial and follow-up hospital consultations, nursing facility.
