Evaluation and Management Service in the Office - Based on Time

Question:

What should be documented when reporting an E/M service based on time in the office?

Answer:

When reporting an E/M (Evaluation and Management) service based on time, documentation must clearly support that time, not medical decision-making, is the controlling factor.

Key elements that must be documented:

• Total time spent

  • Document the total number of minutes personally spent by the provider on the date of the encounter.

  Documentation Example: “I spent a total of 45 minutes on this patient’s care today, including reviewing prior records, evaluating the patient, counseling on diabetes management, adjusting medications, and documenting the encounter.”

• Activities performed

  • You should indicate the types of activities included in that time, such as:

    • Reviewing tests/history before the visit.

    • Obtaining history and performing an exam.

    • Counseling and educating the patient/family.

    • Ordering medications, tests, or procedures.

    • Communicating with other healthcare professionals.

    • Documenting in the EHR.

    • Care coordination.

• Date specificity

  • Time must reflect work performed on the same calendar date as the encounter. Time spent on procedures must be excluded from the E/M time. Time spend on procedures must be excluded from the E/M time.

• Provider-specific time

  • Only include time personally spent by the billing provider (and qualified healthcare professionals if applicable per payer rules).

  • Exclude time spent by ancillary staff.

• Medical necessity

  • Documentation should still support why the visit was necessary (chief complaint, reason for care), and a medically appropriate history and/or examination.

  • A summary of counseling/topics discussed can strengthen the record.

Exact start/stop times are not required (total time is sufficient).

*This response is based on the best information available as of 06/04/26.