Q&A: Reporting shared visit services using the 2021 E/M guidelines

Q: During an outpatient visit, a nurse reviews the patient’s medical history and a physician performs an examination in the presence of the nurse. If you adhere to the 2021 E/M guidelines and use time as the controlling factor for code selection, can you report one E/M code for these shared services?

A: Per the 2021 E/M guidelines, effective January 1, providers may use the time they spend working with or on a patient as the basis for CPT visit code selection. Activities that may be factored into the total time are:

• Care coordination (when not separately reported)
• Counseling and educating the patient/family/caregiver
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver
• Obtaining and/or reviewing separately obtained history
• Ordering medications, tests, or procedures
• Performing a medically appropriate examination and/or evaluation
• Referring and communicating with other healthcare professionals (when not separately reported)

In cases where two providers perform distinct services during an encounter (i.e., the visit is split or shared), the physician should use individual times to calculate a total time for the visit.

Consider a similar scenario with times listed for the visit services:

A non-physician practitioner [NPP] reviews the intake form done by the patient and medical assistant (six minutes) and conducts and interview with the patient for additional history and exam (five minutes). The physician then performs an additional examination in the presence of the NPP, discusses the patient case, orders diagnostic testing, and completes the note (13 minutes).

The physician would calculate the time it took it complete all these tasks: 6+5+13 = 24 minutes. If the physician adheres to the 2021 E/M guidelines and uses time as the controlling factor for code selection, he or she would report E/M code 99202 (outpatient E/M visit for a new patient, requiring 15-29 minutes of total time spent on the date of the encounter)* or 99213 (outpatient E/M visit for an established patient, requiring 20-29 minutes of total time spent on the date of the encounter).*

*Note: CPT code descriptors have been updated for 2021 and do not take effect until January 1.

Editor’s note: This question was answered by Doris Branker, CPC, CIRCC, CPMA, CPC-I, CANPC, CEMC, president of DB Healthcare Consulting, during the DecisionHealth webinar, “E/M Update: Prepare Your Pain Practice, Protect Your Revenue.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.