When time is the primary determinant, which factor is used to determine the E/M level for an office visit?

When time is the primary determinant, which factor is used to determine the E/M level for an office visit?

• A. The total time spent with the patient on the encounter.
• B. The number of exam elements documented.
• C. The physician's personal preference.
• D. The patient's insurance type.

Answer: (A)

When time is the factor used to set the E/M level, the clinician determines the level by the total time spent with the patient on the encounter date. This includes all time—face-to-face as well as counseling and coordination of care and related non-face-to-face activities—so the overall duration maps to a specific level. The other factors don’t drive the time-based approach: simply counting the number of exam elements isn’t what sets the level when time is primary; the physician’s personal preference isn’t allowed to determine the level; and the patient’s insurance type has no bearing on E/M coding.

When time is the factor used to set the E/M level, the clinician determines the level by the total time spent with the patient on the encounter date. This includes all time—face-to-face as well as counseling and coordination of care and related non-face-to-face activities—so the overall duration maps to a specific level. The other factors don’t drive the time-based approach: simply counting the number of exam elements isn’t what sets the level when time is primary; the physician’s personal preference isn’t allowed to determine the level; and the patient’s insurance type has no bearing on E/M coding.