Evaluation and Management Tip of the Month

Evaluation and Management Tip of the Month July 2026

When choosing the appropriate level of Evaluation and Management (E&M) service, providers have the option of choosing to use either Medical Decision Making (MDM) or Time. Each E&M service level has a minimum of time necessary for that particular level.  Providers need to understand which activities can be counted toward the total time spent and which cannot be counted.

What is included when calculating time for use in determining Evaluation and Management Service Level

• When time is being used to select the appropriate level of a service, the time personally spent by the physician assessing and managing the patient on the date of the encounter is summed to define total time.
• The appropriate time should be documented in the medical record when it is used as the basis for code selection.
• Physician/other qualified healthcare professional (QHP) time includes the following activities, when performed:
  • Preparing to see the patient (e.g., review of tests).
  • Obtaining and/or reviewing separately obtained history.
  • Performing a medically appropriate examination and/or evaluation.
  • Counseling and educating the patient/family/caregiver.
  • Ordering medications, tests or procedures.
  • Referring and communicating with other healthcare professionals (when not separately reported).
  • Documenting clinical information in the electronic or other health record.
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
  • Care coordination (not separately reported).

It is imperative to remember that staff time cannot be counted. As well, time spent does not include any time spent in the performance of other separately reported service(s).