Time and care outside the office

Where you are

MDM is not the only selection method for every E/M family. When the applicable family permits time, a supported total can determine the level. Other families use a different method. Start by checking which method is allowed before adding minutes.

This lesson uses original time worksheets and public Medicare policy. Keep exact entry thresholds and complete qualifying-activity instructions in your current authorized reference. Do not apply an office rule automatically to hospital, emergency or prolonged services.

Choose a permitted method

CMS explains that most E/M visit families allow selection by MDM or practitioner time, but some do not offer that choice. Emergency department visit levels use MDM; critical care follows its time-based service rules. History and examination length do not independently determine the level under the revised guidance. [em-compliance-cms, Selecting the E/M Service Level]

Before calculating anything, write “method permitted” on the worksheet and identify the source. This prevents a common error: correctly adding minutes for a family whose visit levels are not selected that way.

A time statement in a note does not automatically force time-based selection when MDM is permitted and appropriately describes the encounter. Whichever method is used, the record must support the reported service.

Build a time ledger

Record the date, practitioner, activity and duration. Then classify each interval under the current instructions: eligible, excluded or unresolved. Do not add an unresolved interval simply because leaving it out produces a lower total.

For an office or outpatient time exercise, check the date-of-service boundary and the applicable practitioner activities in the book. Separate time belonging to another billed service. Distinguish the clinician's work from staff work and patient waiting time. These are different facts even when all appear in a clinic schedule.

Use a ledger instead of one unexplained total when you are learning. It exposes double counting and makes it easier to review a disputed interval. A final clinical record may state a supported total, but your exercise worksheet should show how you understood it.

Worked time arithmetic

Original fictional worksheet, September 9, 2026: the exercise states that three non-overlapping intervals meet the applicable office E/M time requirements—seven minutes of preparation, eighteen minutes of evaluation and counseling, and six minutes of same-day documentation and coordination. It also states that eight minutes belong to a separately reported procedure and are excluded.

The eligible total is 7 + 18 + 6 = 31 minutes. Do not add the eight excluded minutes to reach 39. The exercise gives the eligibility decisions so you can practice arithmetic; in a full chart, you must establish those decisions from the actual record and instructions.

Now the patient spends twelve additional minutes waiting for transportation. Those minutes do not become practitioner work merely because the patient remains in the office. Keep the clinical work ledger separate from elapsed building occupancy.

Meet the full threshold

When time selects the E/M level, CMS requires the full applicable time. The general midpoint convention used for some other timed services does not apply. [em-compliance-cms, Selecting the E/M Service Level]

For arithmetic practice only, imagine an entry requiring at least thirty minutes. A supported total of twenty-nine minutes has not reached thirty. This is a hypothetical threshold, not a replacement for an actual CPT entry. Find the real threshold for the selected family and status in your book.

Do not round a short total upward because the visit was close to the next level. If the documented time is unclear or contradictory, resolve the record rather than selecting whichever total produces the preferred result.

Hospital inpatient and observation work

Current E/M organization combines hospital inpatient and observation visit families, but the actual patient status, dates and service type still matter. Identify initial, subsequent, admission-and-discharge or discharge work under the relevant instructions. A merger of code families does not erase the encounter timeline. [em-cms, pp.4,11–13]

For an original fictional chart, write admission or observation start, each professional encounter and discharge on separate lines. If all events occur on one date, review the same-day requirements. If discharge occurs later, review the applicable separate-day instructions. Do not use a familiar office time threshold to decide hospital reporting.

This course's later cases supply complete timelines. At this stage, practice extracting dates and encounter types accurately before selecting the final entry.

Home, residence and nursing facility are not one setting

CMS's current guidance describes a combined home or residence family that includes specified residential settings. Nursing facility services have their own family and instructions. Establish the actual place and service before choosing between them. [em-cms, pp.14–15]

A note saying “seen where the patient lives” is not enough to distinguish a private home, assisted living residence and nursing facility. Use the documented setting. Then check the appropriate status and permitted selection method in the current reference.

Do not infer a place-of-service code from the patient's age or diagnosis. Residence type and clinical condition answer different questions.

Split or shared services need role and time evidence

Medicare's split or shared E/M policy concerns eligible facility visits furnished by a physician and a nonphysician practitioner in the same group. The billing practitioner must perform the substantive portion under the applicable rule. This is different from simply adding office staff time to a physician's visit. [em-compliance-cms, Split or Shared E/M Service]

For applicable visits, the substantive portion can be more than half of total time or the substantive part of MDM. Critical care and prolonged services have time-specific requirements. Identify the service family before deciding which test applies. [em-cms, pp.18–21]

Count an interval spent jointly meeting with or discussing the patient once. Preserve the individual and shared intervals. Medicare also requires the record to identify both practitioners; the practitioner furnishing the substantive portion signs and dates it, and the claim identifies the split or shared service with modifier FS. These requirements do not make an otherwise ineligible setting qualify. [em-cms, pp.18–20]

A final method check

Before accepting a time answer, ask whether the family permits it, whether the qualifying work and date boundary are satisfied, whether any interval belongs elsewhere, and whether the full threshold is met. For shared work, identify the relevant practitioners and substantive-portion rule.

These questions are useful under exam pressure because they prevent arithmetic from hiding a wrong reporting premise. A correct sum of ineligible minutes is still an incorrect coding answer.

Book drill

Find the time instructions for office/outpatient, hospital, emergency department, home/residence and nursing facility services. Note which method each family permits. Rework the thirty-one-minute exercise and explain why the excluded procedure interval and waiting interval do not increase its stated eligible total.

Checkpoint

Explain why a twenty-nine-minute total does not meet a hypothetical thirty-minute threshold. Distinguish elapsed appointment time from eligible practitioner time. Finally, identify why a split or shared facility service requires more evidence than two practitioner names in a note.

Compare your time worksheet

Use the permitted method and count only eligible, supported work. Meet the full threshold without midpoint rounding. Preserve setting, dates and practitioner roles, and apply the relevant split or shared rule when that service actually qualifies.

Sources

1. CMS — Medicare Provider Compliance Tips: Evaluation and Management Services. Current 2026 page. Accessed 2026-09-10.
2. CMS — Evaluation and Management Services MLN006764. May 2026. Accessed 2026-09-10.