- Since 2021 any office visit can be coded by total physician time on the calendar day instead of by MDM; counseling-heavy and coordination-heavy visits often land a level higher by time.
- Document the exact minutes and what they were spent on. A range, or a missing number, leaves an auditor nothing to verify.
- Past 54 minutes for an established patient, a prolonged services code goes on top of a 99215 that was itself selected by time.
- A preventive visit (99381-99397) and a same-day problem E/M (99202-99215) are both codable when a distinct problem is addressed; the E/M carries modifier 25 and its own section of the note.
- The E/M is subject to the patient's deductible even when the preventive visit is fully covered, so tell the patient before the bill does.
Sometimes the minutes beat the decision making
Since January 1, 2021, any office or outpatient E/M code can be selected by total physician time on the date of service, with no need to show that counseling dominated the encounter. Counseling, record review, and coordination often code a level higher by time than by MDM.
Coding by Time
Time and MDM are the two routes to a level for a problem-oriented visit; take whichever supports the higher code as long as the note honestly reflects it.
What Counts as Total Time
Total time includes these activities by the physician (or qualified health professional) on the calendar date of the visit:
- Preparing to see the patient: reviewing records, labs, and imaging before the visit
- Obtaining and reviewing separately obtained history and patient care documents
- Performing the examination and evaluation
- Counseling and educating the patient or their family
- Ordering medications and tests, and reviewing test results
- Independently interpreting results and communicating them to the patient or family
- Arranging referrals and communicating with other clinicians
- Documenting the clinical information (writing the note) in the EHR
Clinical staff time, the patient's wait, unrelated administrative work, and time on a separately reported procedure do not count: if you code the knee injection, the injecting minutes belong to it.
The Time Thresholds (Office and Outpatient)
| CPT Code | Patient Status | Total Time Range | wRVUs |
|---|---|---|---|
| 99202 | New | 15-29 min | 0.93 |
| 99203 | New | 30-44 min | 1.60 |
| 99204 | New | 45-59 min | 2.60 |
| 99205 | New | 60-74 min | 3.50 |
| 99212 | Established | 10-19 min | 0.70 |
| 99213 | Established | 20-29 min | 1.30 |
| 99214 | Established | 30-39 min | 1.92 |
| 99215 | Established | 40-54 min | 2.80 |
An established patient who scores as low complexity, a 99213 by MDM, becomes a 99214 once documented total time reaches 30 minutes, and a 99215 at 40. The gap between 99213 and 99215 is 1.50 wRVUs on one encounter.
When Time Works Better Than MDM
Time wins in visits heavy on counseling, coordination, or discussion, even when the MDM table lands lower:
- A new diagnosis needing extensive education. The MDM might read as moderate, but you spent 45 minutes.
- A complex patient whose outside records, imaging, or specialist notes you reviewed before the visit.
- A patient with multiple specialists whose care you coordinate by same-day calls and documentation.
End every encounter with two questions: what was the highest-risk thing I decided, and how many total minutes did I spend on this patient today, pre-visit and post-visit work included? Code by whichever supports the higher level.
How to Document a Time-Based Visit
State the total as an exact number of minutes, never a range, and name what it was spent on; one named component is enough. "Total time spent in preparation, evaluation, counseling, and documentation for today's visit: 42 minutes" does the job.
Beyond the Highest Threshold: Prolonged Services
Past 54 minutes for an established patient, the upper bound of a 99215, a prolonged services code goes on top, but only if the 99215 was itself selected by time; one reached by MDM with no documented time cannot carry the add-on. Codes, thresholds, and payer differences are in the prolonged services guide.
Preventive Visits with a Same-Day E/M
The annual exam that turns into a real visit
A patient comes in for the annual exam and brings up a new problem. You can code both the preventive visit and a problem-oriented E/M when the problem work is significant and separately identifiable, with modifier 25 on the E/M and its own section of the note. The full rule, the documentation test, the deductible conversation, and a worked example live in AWV With an E/M on the Same Day; this section covers the preventive side of the pairing.
The Two Types of Services Involved
Preventive visits (99381-99397) use neither MDM nor time; they are coded by age and new/established status and cover preventive evaluation, health maintenance, counseling, and screenings.
| Preventive Code | Patient / Age | Type |
|---|---|---|
| 99381 / 99391 | Infant (under 1 yr) | New / Established |
| 99382 / 99392 | Early childhood (1 to 4) | New / Established |
| 99383 / 99393 | Late childhood (5 to 11) | New / Established |
| 99384 / 99394 | Adolescent (12 to 17) | New / Established |
| 99385 / 99395 | Adult (18 to 39) | New / Established |
| 99386 / 99396 | Adult (40 to 64) | New / Established |
| 99387 / 99397 | Adult (65+) | New / Established |
The problem-oriented E/M (99202-99215) is leveled by MDM or time in the usual way. The Medicare Annual Wellness Visit (G0438/G0439) is a health risk assessment and care planning service rather than a physical exam, but the same-day E/M rule applies to it exactly as it does to a traditional physical.
When the Same-Day E/M Is Appropriate
New chest pain that gets its own evaluation and an EKG, or a new skin lesion you evaluate and biopsy, clears the bar; a passing mention of a stable, already-managed condition does not. The test itself is in the AWV guide.
What the Documentation Must Show
The E/M gets its own section with the problem, assessment, and plan; a single blended narrative is the usual denial. A header such as "Additional Problem Addressed" or "Separately Identifiable E/M Service" is not required but removes the ambiguity, and if you level the E/M by time, count only the problem-oriented minutes.
The Deductible and Cost-Sharing Difference
Preventive services are typically covered without cost-sharing under the ACA; the separately coded E/M is subject to the deductible, so a brief heads-up at check-in or checkout prevents the complaint. The Medicare version of that conversation is in the AWV guide.
Sources and Further Reading for This Chapter
- American Medical Association, Evaluation and Management (E/M) Coding. https://www.ama-assn.org/topics/evaluation-and-management-em-coding
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician