In face-to-face evaluation and management coding, time measurement includes which activities?

• A. Time spent in the waiting room prior to seeing the patient
• B. Time spent face-to-face with the patient and/or family including obtaining history, performing an examination, and counseling
• C. Time spent documenting the encounter after the visit
• D. Time spent coordinating care with other providers by telephone after discharge

Answer: (B)

In time-based face-to-face E/M coding, the time you count is the time spent on the date of the encounter with the patient and/or family, specifically the activities that occur during the actual visit. The key components you’re counting are the history you obtain, the examination you perform, and the counseling you provide to the patient and/or family. Waiting room time, and time spent on documentation or post-visit coordination outside the face-to-face encounter, are not included in the primary time measurement for determining the level of service. So the best answer is the time spent directly with the patient and/or family during the encounter, including history, exam, and counseling.