Time is a Tool, Not a Rule

Time vs. MDM: Understanding Your Options for E/M Level Selection

Since the 2021 revision of the CPT® Evaluation and Management (E/M) guidelines,  there has been a welcomed shift toward simplifying how physicians document office and outpatient visits. One key refinement was how time is defined and applied, allowing for total time on the date of the encounter, not just face-to-face time. However, despite  AMA’s efforts, confusion still lingers, especially around the misconception that both time  and medical decision making (MDM) must be documented, or that whichever supports  the higher level “wins.” Let us set the record straight. 

You Do Not Need Both 

Here is the first and most important truth: You do not need to document both time and  MDM. The AMA guidelines are structured to allow for either. You choose the path that best supports the encounter. 

Let us look at it this way: 

• If your visit was time-intensive, perhaps counseling, coordination of care, or extended discussions dominated the encounter, select the code based on time.
• If the complexity of the problems, data reviewed, and risk management drives the service, use MDM. 

This dual-path approach is not new. Time has always been an option for E/M level selection. What has changed is that now, total time includes both face-to-face and non-face-to-face work performed by the physician or qualified health professional on the same calendar day. 

When Time Dominates, Use It 

The AMA specifically states that time should be used when it dominates the visit. In other words, do not default to time just because it might give you a higher level. That is not the spirit of the guidelines. Rather, time-based coding should be reserved for visits where the majority of the physician’s effort was spent on activities measured by time,  such as counseling or care coordination. This does not describe the average encounter. Also, when using time, documentation must clearly include:

• The total time spent by the rendering provider on the day of the encounter.
• A breakdown or description of activities (e.g., reviewing records, counseling, care coordination). 

Remember, it is total time on the date of the encounter, not just face-to-face time, and it must still be tied to the date of service.

MDM: A Closer Look at the “Work” 

If you are not selecting by time, you are selecting based on MDM, which means: • Number and complexity of problems addressed 

• Amount and/or complexity of data reviewed 
• Risk of complications, morbidity, or mortality of patient management. Each of these has clear definitions and criteria set by the AMA. Two of the three must be met or exceeded to select a level of service. 

For many physicians, MDM often provides a more natural reflection of the cognitive work involved in diagnosing, assessing, and managing patient care. When properly documented, MDM often supports the same or higher level than time and avoids the pitfalls of trying to remember and report every minute of the day. 

What Happens When You Document Both? 

Let us say a physician documents both time and MDM, intending to “pick the higher  one.” That is a well-intended strategy, but it can create confusion in an audit. If the time does not quite meet the threshold but the MDM does, or vice versa, which will the payer consider? If the documentation is not clear on which methodology was chosen, you could inadvertently undermine the validity of the service level reported. The safest practice is to choose your path and document accordingly. Do not muddy the waters by trying to hedge your bets. 

Best Practices for Documentation Clarity 

1. Choose upfront. Decide whether the visit is time-based or MDM-based before documenting. 
2. State it clearly. If you are coding based on time, say so, such as, “Today’s visit is  based on total time spent…” 
3. Avoid blending methodologies. Do not document both unless clearly identifying one as the basis for code selection.
4. Educate your team. Everyone, including providers, scribes, and coders, should be on the same page. 

Moving Forward: Two Pathways For Code Selection

The 2021 AMA guidelines did not change the fundamental nature of E/M coding. They simply clarified it. Physicians now have two distinct pathways for code selection:

• Time: When the day’s work is defined by time. 
• MDM: When the clinical complexity best represents the service. They are not meant to be used together as a “choose-your-own-adventure” coding style. Select the method that best reflects the actual work performed and document with intention.

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