Time Must Be Distinct and Documented for Certain Encounters

When an evaluation and management (E/M) service is provided during the same encounter as certain time-based services, provider documentation must clearly distinguish the time spent on each service. Without this distinction, coders may not have the information needed to assign codes accurately and compliantly. 

Clear documentation is particularly important because CPT® includes specific guidance about how time may be counted and reported for different services. Failing to document time separately can create coding challenges, increase the need for provider queries, and affect coding accuracy. 

The CPT code book contains several distinct time-based coding guidelines that prohibit overlapping time calculations between services. 

Examples include: 

These guidelines reinforce the importance of documenting time separately whenever multiple services are provided during the same encounter. 

Most CPT E/M codes can be reported based on either time or medical decision making (MDM). However, providers should still document the duration of time spent performing time-based services, even when MDM is used to support the E/M service. 

Documenting the duration of each service helps ensure that coders can accurately assign both the E/M service and any separately reportable time-based service provided during the encounter. 

The following examples illustrate how documentation quality can affect coding when a patient receives both psychotherapy and E/M services during an outpatient encounter. 

Provider documentation: 

“80 minutes total time spent with patient.” 

In this scenario, the single-path coder responsible for both professional and facility coding cannot determine which psychotherapy code should be assigned:

Because the provider didn’t specify how much of the time was spent providing psychotherapy services, a query is required to obtain the missing information. 

Provider documentation: 

“60 minutes spent providing psychotherapy services.” 

In this case, the single-path coder can assign psychotherapy code 90838 and separately report an E/M code based on the level supported by the documentation. 

This example demonstrates how clear documentation allows coding decisions to be made without additional clarification from the provider. 

Supporting Documentation Improvement 

When a provider demonstrates a recurring pattern of incomplete or unclear documentation for time-based services, hospitals and health systems should facilitate clinical documentation training and monitor documentation quality after training is completed. 

Improving documentation practices can help reduce coding questions, support compliant code assignments, and improve overall documentation quality.

When E/M services occur alongside other time-based services, clear and distinct documentation of time is critical. By documenting the duration of each service separately, providers can support accurate code assignments, reduce the need for queries, and help maintain compliance with CPT® reporting guidelines.