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Got coding questions? Your Academy has the answers. Each month we feature a member’s question with an answer provided by AAPM&R’s Reimbursement and Policy Review Committee (RPRC).

Q: How should a clinician document when billing an evaluation and management service based on time? Is this a risky way to bill?

A: A clinician in the outpatient setting can bill an evaluation and management service based on time if 50% or more of the face-to-face time spent with the patient is spent conducting counseling and coordination of care. In instances where billing based on time is appropriate, the documentation should state specifically what was discussed as a part of the counseling and coordination of care. Additionally, the documentation should include the amount of time spent face-to-face with the patient and what portion of that time (must be 50% or more) is spent on counseling and coordination of care.

Requirements for time-based billing differ somewhat for inpatient visits. For inpatient evaluation and management services, the clinician must spend 50% or more of the unit/floor time (as compared to face-to-face time) on counseling and coordination of care. Unit/floor time includes the time present both at the bedside as well as on the hospital unit. Finally, note that as with all billing, medical necessity for services billed based on time must be well documented. If the service is medically necessary and documented appropriately, time-based billing is not a risky way to bill. Review of the 1995 & 1997 Evaluation and Management Guidelines as well as other CMS resources is also recommended.  

Find additional resources related to reimbursement here. Do you have a coding or billing question? Contact AAPM&R at codingquestions@aapmr.org for assistance. 

Accurate coding is the responsibility of the provider. This article is intended only as a resource to assist in the billing process.