Time is of the essence: Decipher how to use time-based E/M documentation standards

Why This Topic Matters

The article matters because it addresses a major shift in how office and outpatient E/M services are documented and selected, which can affect workflow, compliance, and code-level selection across practices and specialties. It helps readers understand the scope of the 2021 changes and the types of guidance practices should review when preparing for the transition.

Article Sections

1. CMS and AMA documentation changes

   Introduces the broader documentation revisions affecting office and outpatient E/M services and outlines the general shift in code selection methods. It also distinguishes the CMS and AMA approaches at a high level.

2. Shifting definitions of time

   Summarizes how the definition of time is being updated for office and outpatient E/M reporting and discusses the role of multiple professionals in the service. It also notes the types of activities that may be considered in time-based reporting.

3. How the AMA defines it

   Describes the AMA’s approach to time-based reporting and the concept of shared or split visits. It explains the general framework for aggregating practitioner time on the date of service.

4. Which activities count for time-based reporting?

   Identifies broad categories of day-of-service activities that may be considered when time is used for office E/M reporting. It also highlights the general boundary between countable and non-countable services.

5. Assess when time is beneficial

   Uses a specialty-focused example to illustrate why some encounters may be better suited to time-based selection under changing documentation standards. The section compares documentation approaches at a high level.

6. Plot prolonged services

   Covers the addition of a new prolonged services concept for office and outpatient E/M services and places it in the context of longer encounters. It explains that the section is part of the 2021 transition framework.

7. Take steps to get ready

   Offers general preparation considerations for practices adapting to the upcoming documentation changes. It emphasizes reviewing workflows, documentation patterns, and code-level impacts.