2021 EM Changes – Time

In this blog series we are going to do a deep dive into the 2021 E/M Changes. During the series I will be referring to the official guidelines from the AMA. Click the link below to download a copy.


In today’s post I am going to address how time will be used to level services in 2021.

Counseling and/or Coordination of Care Caveat Goes Away

Currently, you have to document that you spent greater than 50% of your visit in counseling and/or coordination of care in order to level your office service based on time. The 2021 changes will allow you to report codes 99202-99215 based on the total time spent regardless of counseling or coordination of care.

“Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.”


Activities You Can Count Towards Your Time

You are going to be pleasantly surprised when you see what activities you will be able to count toward your total time. Keep in mind though that the time for these activities only count if they are performed on the date of the service. You cannot count time spent prior to or after a visit. To properly document your time you need to document the total time spent and then detail the activities that you performed for the visit.

  • Preparing to see the patient (ie, reviewing tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate exam
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, test, or procedures
  • Referring and communicating with other health care providers
  • Documenting clinical information in the EHR or medical record
  • Independently interpreting result (not separately reported)
  • Communicating results to patient/family/caregiver
  • Care coordination (not separately reported)

Do Not Count Time Spent on Separately Reported Activities

You may have noticed that they keep mentioning (not separately reported). What they mean is if you are going to bill it separately do not count the time for that as EM time. For example, if you do an EKG on a patient and bill for it, do not also count the time it took you to do the EKG as part of your EM. Don’t double dip. It is as simple as that.

Time Thresholds Change in 2021

Now let’s take a peak at how the time thresholds will look in 2021.

CPT CodeCurrent Time2021 Time

In the next blog post we will discuss how these time changes will affect prolonged services.