Time based E&M dominated by counseling and/or coordination of care – When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care.

STANDARD

Services billed according to time are either services where the CPT codes explicitly state required time increments (i.e., individual medical psychotherapy, critical care services, and prolonged services), or E/M services where time dominates (more than 50% of the encounter) due to counseling/coordination of care.

If time is the driving factor in code selection, the teaching physician must document in the medical record the total amount of time he/she spent face-to-face with the patient and/or family in counseling and/or coordinating care.

Service times are defined as:

• face-to-face time for office/outpatient visits and
• both face-to-face time and/or unit/floor time for hospital/inpatient visits.

For E/M services where a Resident or Fellow is involved in the encounter and the level of service is determined using time, the teaching physician must be present during the time period for which the claim is made. Time spent by a Resident or Fellow in the absence of a teaching physician may not be counted.

Counseling

Involves a discussion with the patient and/or family about one or more of the following:

1. Diagnostic results, impression and recommended procedures;
   2. Prognosis;
   3. Risks and benefits of treatment options;
   4. Instructions for treatment and/or follow-up;
   5. Importance of compliance with chosen treatment options;
   6. Risk factor reduction; and/or
   7. Patient and Family education.

Counseling need not be provided at every patient encounter.

Coordination of Care

Coordination of care involves arranging ongoing care for the patient with other providers.

When counseling or coordination of care constitutes more than 50% of the visit, the time spent is considered the “KEY” factor in determining the level of E&M services.

The following should be documented in the medical record:

1. The total time of the visit;
2. Actual time spent counseling; (the time is the actual face-to-face time spent with the patient and/or family, not the total time of the visit) and
3. Topic of the counseling session and/or coordination of care.

REGULATORY REFERENCES

MCP 100-04/100.1.4 (Rev.811, Issued: 01-13-06, Effective: 01-01-06, Implementation: 02-13-06)

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.