Total time is used in lieu of face-to-face time and is not limited to use when more than 50% of the office evaluation and management (E/M) service (99202–99205, 99212–99215) was spent in counseling and/or coordination of care. Reporting based on the total time spent by a physician or other qualified health care professional (QHP) applies only to office E/M services in 2021. Pediatricians can select a level of office E/M service based on total time or medical decision-making for each office E/M service provided. Time-based reporting requirements for most other E/M services (eg, consultations, home visits) are unchanged.

The use of total time in selecting a code for office E/M services has raised some questions and concerns about how time must be documented. Current Procedural Terminology (CPT®) guidelines for office E/M services do not provide distinct guidance on documentation of total time with the...

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