Billing for Documentation Time
Yes, you can include documentation time in your billing when using time-based billing codes, and the 8 minutes spent documenting after a 12-minute face-to-face visit can count toward the total 20-minute billing threshold.
Understanding Time-Based Billing Under Current Guidelines
The 2021 American Medical Association evaluation and management (E/M) guideline changes fundamentally altered how physicians can bill for outpatient visits. The updated guidance explicitly accounts for provider time outside of face-to-face encounters, recognizing that clinical work extends beyond direct patient interaction 1.
What Counts as Billable Time
Under time-based billing, you can include:
- Face-to-face time with the patient (your 12 minutes) 1
- Documentation time on the same day of the encounter (your 8 minutes) 1
- Review of records and test results
- Care coordination activities
- Communication with other providers about the patient
The total time spent on these activities determines your billing level, not just the face-to-face component 2.
Key Requirements for Time-Based Billing
You must document the total time spent and specify that you are using time as the basis for code selection 3. The documentation should clearly state:
- Total time spent on the date of encounter
- That time was the determining factor for code selection
- Activities performed during that time
Common Pitfalls to Avoid
Do not confuse "active" versus "idle" EHR time - only time actively spent on patient-related tasks counts 3. Simply being logged into the electronic health record without actively working on the patient's care does not qualify 3.
Documentation must occur on the same calendar day as the encounter for it to count toward that visit's time 4. Time spent days later completing notes cannot be retroactively applied to the original visit billing.
Economic Considerations
Time-based billing particularly benefits physicians with longer patient visits. For return visits lasting 20 minutes or longer, time-based billing generates higher revenue compared to medical decision-making (MDM)-based billing 2. However, for very brief 10-15 minute visits, MDM-based billing may be more advantageous 2.
In your specific scenario with a 20-minute total time allocation (12 minutes face-to-face + 8 minutes documentation), time-based billing is appropriate and likely optimal compared to coding based solely on the complexity of medical decision-making 2.