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Question: Which aspects of a provider鈥檚 services count for time when leveling evaluation and management (E/M) services?

Pennsylvania Subscriber

Answer: Many of the sort of behind-the-scenes aspects of provider care may be able to be categorized as time when leveling E/M services. However, it鈥檚 crucial to remember that when coding E/M services, you need to meet the time threshold listed; you cannot round up like you can for some other types of services. So even one minute short of the requirement listed in the descriptor means that your provider isn鈥檛 actually reaching that service level.

Remember: If your time threshold reaches the level required to count as prolonged services, you have to reach the full 15 minutes to report 1 unit, and another full 15 minutes for 2.

Top tip: Multiple providers of the same group specialty seeing a patient in a day can be coded together as if they were one person, because only one individual can bill an E/M code, as long as there isn鈥檛 any overlapping time 鈥� overlapping time can only be counted once.

Here are some of the services that can be included when leveling time:

• Preparing to see the patient, including reviewing tests
• Obtaining history
• Performing medically appropriate examination or evaluation
• Counseling and educating the patient (or family or caregiver)
• Ordering medication, tests, or procedures
• Referrals or communications with other healthcare professionals
• Documenting clinical information in electronic health records (EHRs)
• Independently interpreting and communicating results
• Care coordination.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC