How is time defined in the office and outpatient setting?

In the office and outpatient setting, time is specifically defined as "face-to-face time" spent with the patient. This encompasses the duration where the healthcare provider is actively engaged with the patient during the visit. It is crucial because many evaluation and management (E/M) coding guidelines emphasize that time is used as a determining factor for coding levels, particularly when counseling and coordination of care dominate the visit.

In this context, only the time spent directly interacting with the patient is considered for billing purposes, excluding any time that is not spent in that direct, face-to-face interaction. Therefore, defining time in this manner aligns with the guidelines set forth by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) regarding the documentation of E/M services. This specificity is important for auditors and coders to ensure accurate billing and compliance with coding standards, reflecting the amount of time dedicated to patient care accurately.