An internist we work with sees a 71-year-old established patient with heart failure, diabetes and a new complaint of dizziness. She spends 12 minutes in the room, then 9 minutes before the visit reading a cardiology note and the last echocardiogram, and 14 minutes after the patient leaves adjusting three medications, writing the note and sending a message to the cardiologist. Her note is leveled by medical decision making at 99213. Her total time on the date of the encounter was 35 minutes, which supports 99214. Nobody told her that, so she billed 99213 for the third year running.
Across a panel of 1,800 patients, that pattern is expensive. It is also the mirror image of the problem we see in audits: notes that state "total time 40 minutes" on every visit, including the 8-minute blood pressure recheck, with no description of what the time was spent on. Both problems come from the same place. The physician was never taught what time-based E/M coding actually counts.
This article is the rule as it stands in 2026, what counts toward total time and what does not, a worked example, and the way we document time so it holds up in an audit. For readers without a billing background: E/M means evaluation and management, the family of CPT codes (99202 to 99215 in the office) that pays for the visit itself rather than for a procedure.
Key takeaways
- Since 2021, office visit codes 99202 to 99215 can be leveled either by medical decision making or by the physician's total time on the date of the encounter, and you choose visit by visit.
- Total time includes face-to-face and non-face-to-face work by the billing physician or qualified health professional on that calendar date: chart review, the exam, counseling, ordering, documenting and coordinating.
- Clinical staff time, travel, separately billed services and work done on a different date never count.
- Under CPT 2024 and later, each code has a single minimum that must be met or exceeded: 99213 is 20 minutes, 99214 is 30 and 99215 is 40.
- Document the total minutes and what they covered in one sentence; identical time statements on every note are the fastest way to get a payer audit.
The rule behind time-based E/M coding
Before January 1, 2021, time could only be used to level an office visit when counseling and coordination took more than half of a face-to-face encounter. The CPT changes that took effect that day, adopted by CMS in the CY 2021 Physician Fee Schedule final rule, replaced that with a simple choice. For 99202 to 99215 you level by medical decision making (MDM) or by total time on the date of the encounter. The history and exam no longer determine the level; they only need to be medically appropriate. On January 1, 2023 the same framework reached hospital, observation, nursing facility and home visits.
CPT 2024 made one more change that still trips people up. The original 2021 version gave each code a time range (99214 was 30 to 39 minutes). Effective January 1, 2024, each code has a single threshold that "must be met or exceeded." Practically the floors did not move, but the language did, and prolonged service reporting is tied to those floors. Here are the office thresholds as they stand in 2026.
| Code | Patient | Minimum total time on the date of the encounter | MDM level if leveled by MDM instead |
|---|---|---|---|
| 99202 | New | 15 minutes | Straightforward |
| 99203 | New | 30 minutes | Low |
| 99204 | New | 45 minutes | Moderate |
| 99205 | New | 60 minutes | High |
| 99211 | Established | No time component; clinical staff visit | Not applicable |
| 99212 | Established | 10 minutes | Straightforward |
| 99213 | Established | 20 minutes | Low |
| 99214 | Established | 30 minutes | Moderate |
| 99215 | Established | 40 minutes | High |
Prolonged services sit on top of the highest code. CPT 99417 is reported for each additional 15 minutes beyond the 99205 or 99215 minimum, so under CPT rules it becomes reportable at 75 minutes for a new patient and 55 for an established one. Medicare does not accept 99417 for office visits. It uses HCPCS G2212, which starts 15 minutes past the top of the old ranges: 89 minutes for 99205 and 69 minutes for 99215. Most Medicare Advantage plans follow the G2212 convention; many commercial plans follow CPT. Your billing system needs both rules loaded by payer, or you will bill prolonged time that the payer defines differently.
What counts toward total time
CPT lists the activities that count when they are performed by the physician or other qualified health care professional (QHP, meaning an NP or PA billing under their own number) on the date of the encounter. We teach them as three blocks: before the patient, with the patient, after the patient.
Before the patient: preparing to see the patient, which is mostly reviewing tests, prior notes and outside records; and obtaining or reviewing a separately obtained history, for example the intake questionnaire the patient completed or the history a family member gave by phone that morning.
With the patient: performing a medically appropriate exam or evaluation; counseling and educating the patient, family or caregiver; and ordering medications, tests or procedures. Time with a family member or caregiver counts even if the patient is not in the room, as long as it is on the same date.
After the patient: referring to and communicating with other health care professionals about this patient, when that communication is not separately reported; documenting the clinical information in the record; independently interpreting results that are not separately billed and communicating those results to the patient or family; and care coordination that is not separately reported. The physician who dictates the note at 6 p.m. is still inside total time. The physician who finishes the note the next morning is not, and that is the single most common error we find.
What does not count, and where practices get it wrong
The exclusions matter more than the inclusions, because the exclusions are what an auditor tests. Time spent by clinical staff does not count. The medical assistant rooming the patient, reconciling the medication list and giving the vaccine adds nothing to the physician's total, no matter how long it takes. Time spent on a separately reported service does not count. If the physician performs a joint injection (20610) and bills it with the visit under modifier 25, the minutes of the injection itself and of documenting it come out of the E/M total. The same is true of an ECG the practice bills as 93000, a skin biopsy, a spirometry test, or advance care planning billed as 99497.
Travel time never counts, and teaching time counts only when it is specific to this patient's management rather than general instruction of a resident or student. Time on a different calendar date does not count toward the visit at all. Reviewing labs on Tuesday for a Wednesday visit is not part of Wednesday's total; if you want credit for it, you do that review on the day of the visit. Finally, when two clinicians from the practice see the patient together, the overlapping minutes are counted once, not twice.
A worked example, minute by minute
Take the internist from the opening. Her established patient visit on the date of the encounter breaks down like this, using her own records and the EHR audit log.
- 7:50 a.m., 9 minutes: reviews the cardiology consult note, the echocardiogram report and the last two visits. Counts (preparing to see the patient).
- 9:10 a.m., 12 minutes: history, focused exam, discussion of dizziness, orthostatic vitals reviewed. Counts (exam, counseling).
- 9:22 a.m., 6 minutes: her medical assistant performs an in-office ECG. Does not count; staff time, and the ECG is billed separately as 93000.
- 9:28 a.m., 4 minutes: physician reads the ECG tracing. Does not count toward the E/M, because the interpretation is paid inside 93000.
- 12:40 p.m., 14 minutes: adjusts the diuretic and two other medications, writes the note, sends a portal message to the cardiologist. Counts (ordering, documenting, communicating with another professional).
Countable total: 9 + 12 + 14 = 35 minutes. That meets the 30-minute floor for 99214 and does not reach 40 for 99215. The MDM also happens to be moderate here (two chronic illnesses with exacerbation, prescription drug management), so either path lands on 99214. Where it matters is the visit whose MDM is low but whose legitimate time is 31 minutes: 99214 by time is correct and defensible, and on a typical commercial fee schedule the gap between 99213 and 99214 is often $35 to $50 per visit. Across 40 such visits a month, that is real money left on the table by a physician who only ever thinks in MDM.
Now the reverse. A 7-minute visit with prescription drug management has moderate MDM on paper, but the physician levels by time out of habit and reports 99212. That is legal, and it is also an underpayment. The rule is simple: on each visit, level by whichever method the documentation supports at the higher level. Practices that mandate "always MDM" or "always time" are leaving money or compliance exposure behind.
Documenting time so it survives an audit
A time statement needs three things: the total minutes, the words "on the date of the encounter" or an equivalent, and a phrase about what the time covered. Our preferred sentence: "Total time on the date of the encounter: 35 minutes, including pre-visit record review, the visit, medication adjustment, documentation and communication with cardiology. Excludes separately billed ECG." That last clause is not required by CPT, but it tells an auditor you know the rule, and in our experience it ends the conversation early.
Three patterns get practices audited. First, cloned time statements: the same "total time 40 minutes" on 96 percent of notes. Payers run that query. Second, the impossible day: a physician with 26 visits, each documented at 35 minutes, has claimed 910 minutes, or more than 15 hours, of E/M work in a clinic day that ran 8 hours. Payer analytics and the OIG both use this test. Third, time without substance: the stated time is the only thing supporting the level and the narrative describes a 5-minute encounter. Turn off any EHR template default that pre-populates a time value.
We run a monthly report of total E/M minutes per physician per day, flag any day over 600 minutes, and read five time-leveled notes per physician per quarter. It takes an hour a month. If you want an outside set of eyes on it, our RCM audit includes a time-versus-MDM sample, and our live courses on E/M coding walk through the exclusions with real notes.
Questions we hear
Can the physician count time spent reviewing results after the patient leaves if the results came back that afternoon?
Yes, if it is the same calendar date and the results are not separately billed. Reading a same-day CBC and calling the patient about it counts. Reading it the next morning does not.
Does the time spent by our NP count if the physician also saw the patient that day?
In the office under Medicare rules there is no split or shared visit; the visit is billed by one clinician, and only that clinician's time counts, with any overlapping joint minutes counted once. In a facility setting, Medicare's split or shared rules apply and the billing clinician must have performed the substantive portion, which since 2024 CMS defines as more than half of the total time or the medical decision making.
Do we have to use time for a long visit that had simple decision making?
No, but you should. A 45-minute visit spent counseling a newly diagnosed patient with straightforward MDM is a 99215 by time if the 45 minutes were the physician's and documented. Coding it 99212 by MDM is not "safe," it is just wrong in the other direction. Pick the method that reflects the work.
What to do this week
- Print the threshold table above and the list of what does and does not count, and put both in front of every physician and NP.
- Pull 20 recent office notes per clinician and check whether the time statement exists, states the date, describes activities and excludes any separately billed service.
- Run a report of total documented E/M minutes per clinician per clinic day for the last 90 days and look at anything over 600.
- Check your billing system's prolonged service rules: 99417 for commercial payers that follow CPT, G2212 for Medicare and the Medicare Advantage plans that follow it.
- Remove any EHR template default that pre-fills a time value.
- Re-level a sample of 99213 visits by time and see how many honestly support 99214; that number tells you whether training is worth scheduling.
