June 10, 2021

Question:
If I use time to select my E/M service in the office, can I just document the total time?

Answer:
No, you must document the actual time along with the activities performed. According to the AMA, list the total time and describe what activities were done. “I spent 45 minutes caring for this patient today, reviewing record from another facility, seeing the patient, documenting in the electronic health record and counseling.

*This response is based on the best information available as of 6/10/21.