The Definition of "Time" in Regards to E/M Services

To meet the criteria of the "time" code, the visit must meet the following conditions:

· The office visit must be dominated by counseling, meaning that more than fifty percent of the time spent with the patient is spent discussing the diagnosis, the test results and treatment options available to the patient. This time can also be spent on patient education and discussing the importance of treatment compliance on the part of the patient.

· You must document the total time of the visit and must document that more than fifty percent of the visit was spent in discussion with the patient. You also need to document the nature of the patient discussion.

Remember, "time" can not be used as a descriptor for patient observation, visits to the emergency room or preventative medicine services. If a visit with a patient meets the above conditions, you can use the "time" code regardless of the level of history, exam or medical decision making made during the course of the visit.

The Impact on Level of Service

The level of service for the E/M code will not impact your billing if you spend more than fifty percent of the patient visit counseling the patient. Instead, you can choose the time element to qualify the billing of your visit. Just be sure to document that more than fifty percent of the time spent was spent in discussion with the patient so that you can properly capture the visit code.

Scheduling Family Visits

It is not uncommon for the family members of some patients to want to speak with you in your office. If you schedule visits with these family members alone without the patient present, you will not be able to bill for the time spent. While this may provide an outstanding level of customer service to your patients and their families, you do deserve to be compensated for your time. Instead of meeting with family members alone, consider scheduling family visits to coincide with a patient's scheduled appointment. If the patient is present during a face-to-face family meeting and the time spent on counseling exceeds fifty percent of the visit, you can capture the revenue for the visit as long as you properly document the progress notes.

Of course it is up to you to decide the proper way for you to discuss patient issues with a patient's family. You do need to be sure, however, that you have the proper privacy forms filled out and that you are authorized to discuss the patient's treatment with his or her family when divulging patient information.

Properly Documenting Your Time

Time can be a significant issue when you are seeing a patient to discuss a variety of concerns. Make sure that you take advantage of the rules that pertain to billing for time. By doing so, you will be able to maximize the revenue coming into your practice and will not go uncompensated for time spent counseling the patients in your care.