Time-based E/M coding can be tricky, and audits often reveal a common mistake: including separately reported services in the total time. CPT® guidelines are clear—time spent on other billable services, travel, or general teaching unrelated to the patient’s management should not be counted toward the E/M service.
What Coders Need to Know
When documenting and coding E/M visits based on time:
- Exclude any time spent performing procedures or services reported separately.
- Exclude travel time.
- Exclude general teaching not specific to the patient’s care.
Failing to carve out these activities can lead to overcoding and potential audit issues. Accurately separating time ensures compliance and strengthens the defensibility of your claims.
Key Takeaway
Always review the operative or encounter documentation carefully and count only time spent on patient-specific management, including both face-to-face and non-face-to-face activities. Correct application of time-based E/M coding reduces denials and audit risk.
Resources: CPT® E/M Guidelines
Meet the Presenter: Susan Bonham, CPC, CEMC, CGSC, COBGC, COPC, AAPC Approved Instructor
Susan brings over two decades of experience in medical coding, auditing, and physician education to her role at Haugen Consulting Group. Throughout her career, she has worked across a wide range of specialties including OB/GYN, general surgery, orthopedics, psychiatry, family medicine, and ophthalmology—bringing a broad and deep understanding of professional fee coding. As a Certified Professional Coder (CPC) and AAPC Approved Instructor holding four specialty credentials, Susan has supported both large health systems and private practices by leading coding teams, performing audits, and providing customized education for coders and providers. Her experience spans practice management, coding quality assurance, and EMR system navigation, with expertise in tools such as EPIC, Allscripts, and Centricity.
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