Are physicians required to document the time spent on each specific task associated with an outpatient visit?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

In a significant departure from the 1995 and 1997 rules, the 2021 revisions to the evaluation and management (E/M) office visit coding documentation requirements no longer include the documented history and physical exam in determining the appropriate level of service (LOS). 

Physicians now have the choice to bill office/outpatient E/M encounters solely based on medical decision making (MDM) or the total time spent on the date of that encounter. The time spent on the encounter includes both face-to-face and non-face-to-face time personally spent by the physician (and/or other qualified health care professional) and may include several activities (see list below).^1,2 

Documenting and coding based on MDM

When documenting and selecting a code based on MDM, consider that MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting management options. MDM in the office or other outpatient service codes are defined by three elements:

• The number and complexity of problem(s) that are addressed during the encounter,
• The amount and/or complexity of data reviewed and analyzed, and
• The risk of complications and/or morbidity or mortality of the patient management decisions made at the visit and associated with the patient’s problem(s), the recommended diagnostic procedure(s), and prescribed treatment(s).¹ 

Documenting and coding based on time

If time is used to determine the E/M LOS code rather than MDM, physicians should include the total amount of time they spent associated with that visit on the date of service.  Besides face-to-face time in the exam room or in a telehealth encounter, this includes prep time and follow-up work on that same date. The CPT® E/M Guidelines include discrete, non-overlapping time spend ranges within the code descriptors correlating to LOS codes. ¹ 

CPT code and time range

99202: 15-29 mins

99203: 30-44 mins

99204: 45-59 mins

99205: 60-74 mins

99211: N/A

99212: 10-19 mins

99213: 20-29 mins

99214: 30-39 mins

99215: 40-54 mins

Important notes

• If using MDM to determine the level of service:
  • There is no requirement to document the total time spent, and there is no requirement to spend the amount of time correlating with the LOS on the encounter¹

Physician/other qualified health professional time includes the following activities (when performed): 

• Preparing to see the patient
• Obtaining and/or reviewing separately obtained history
• Performing a medically necessary appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests or procedures
• Communicating with other health care professionals (when not reported separately)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver
• Care coordination (not reported separately)²

Do not count time spent on the following:

• Performance of other services that are reported separately
• Travel
• Teaching that is general and not limited to discussion that is required for the management of a specific patient¹

By leveraging the 2021 revisions to the E/M office visit documentation requirements, health care organizations can streamline documentation, potentially increase reimbursement due to simplified documentation, improve workflows, and reduce administrative burden—allowing physicians to focus more on patient care.

• CPT Coding System H-70.974

• January 2022 MLN Booklet: Evaluation and Management Services Guide (PDF). Accessed May 2022.
• Nordic-AMA 2021 E/M Updates: What Will Happen to the Physician Note (PDF). Accessed May 2022.
• AMA CPT® Evaluation and Management Office or Other Outpatient and Prolonged Services Code and Guideline Changes (PDF). Accessed May 2022.
• AAFP Tips For Using Total Time to Code E/M Office Visits in 2021. Accessed May 2022.

1. American Medical Association. CPT® Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes.; 2021. Accessed May 2022. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
2. Joseph C, Levy B. 2021 E/M Updates: What Will Happen to the Physician Note. Nordic-American Medical Association; 2021. Accessed May 2022. https://www.ama-assn.org/system/files/2021-03/ama-em-updates-physician-note-white-paper.pdf

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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.

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Last reviewed in March 2022.