Time Reporting for E/M Levels

November 2, 2023

Question:
Is it best practice to bill 99202-99215 based on time only?

Answer:
CPT codes 99202 to 99215 no longer require that the History and Examination be key factors in determining the level of Evaluation and Management (E/M) code. Instead, the E/M code is dependent on:
• Level of Medical Decision Making (MDM) applied during the encounter, or
• Total time spent on the visit.

Providers may choose which component – MDM or time – they would like to use as long as the documentation supports the code chosen.

Reporting time is an option when selecting the level of Evaluation and Management service whether or not counseling or coordination of care dominates the service. Time is calculated as the total time spent personally by the provider and/or QHP on the date of the encounter this includes both face-to-face and non-face-to-face time. Remember, there must be medical necessity to support reporting the E/M service by time. Typically, we do not expect vascular surgeons to code E/M services solely based on time.