What Counts as Time for an Encounter and Where Time is Tracked

Version 20.11
  Take me to all 2021 Office Visit E/M Coding Resources!

Important Note about the Development of these Features

It is important to note that the details of what “should” and “should not” count are evolving and the developments in OP can only align with what we know to be true at the time of development. We expect that there will be modifications to the enhancements as more is learned from both the industry and our practices. All coding recommendations are suggested based on information that can be tracked in OP.

"A reminder that time tracking is guidance only. It's meant to assist you and offer guidance. It should not be taken as gospel and absolutely accurate. It should be used as your sanity checker. It uses time tracking to offer coding recommendations but it is up to the Rendering provider to confirm accuracy and choose a code based on what actually happened." - Sue Kressly, MD, FAAP

Global Preferences to Consider with Time-Tracking

Time-tracking starts and stops depending on where in the system the provider is working with the patient focused on the date of the patient's Encounter (from 12:01AM - 11:59PM). Because of this fluid tracking, there are a couple of OP setup items that your practice may already have in place that will impact the accuracy of time-tracking for your providers. These settings are located in the Security tab of Global Preferences (Admin tab  Global Preferences > Security tab) and can be changed by a Practice Administrator, if necessary:

IFYour practice's OP is set up to log a user out of OP after a specific amount of time...THENTime-tracking will stop when the logout occurs. 
What this means: This is an important security feature and should not be disabled. However, this may lead to untracked-time spent with the patient. The provider will just need to be aware of this when confirming their Total Time during visit coding. Or, the practice can make a decision to increase the amount of time before the logout occurs.
IFYour practice's OP is set up to allow users to be logged-in on multiple workstations...THENTime-tracking will not be accurate for the visit. OP cannot keep track of time for a provider logged in on multiple workstations.
 Do This: Navigate to the Security tab of Global Preferences and select the checkbox to disallow simultaneous login on multiple workstations.

Click the bullets below to learn more about Time-Tracking in the following sections:

Categorization of Time

Tracked-time is categorized into 3 buckets that are displayed for the provider during Encounter coding so that he or she can recall where their time was spent for the visit.

Pre-visit Preparation
Preparation that occurs before the patient is seen.
Intra-visit Work*
Work done by the provider during the visit.
Post-visit Work*
Work done by the provider after the visit.

* Your practice can decide the Visit Stage that categorizes the time-tracking into this bucket and make that setting in Global Preferences. Click here to learn how to set your practice's Intra-visit Work and Post-visit Work Visit Stages. If no setting is made, all time-tracking is displayed as Total Time, without categorization. This does not mean that time is not tracked. It simply means that it is not divided into buckets.

What Does and Does Not Count as Time for an Encounter

Counts

• Provider time spent logged into OP on the date of the patient's Encounter

• Reviewing tests in preparation of seeing the patient

• Obtaining and/or reviewing separately obtained History

• Performing a medically appropriate examination and/or evaluation

• Counseling and educating the patient/parent/caregiver

• Ordering Medications, Tests, or Procedures

• Referring and communication with out healthcare professionals (when not separately reported)

• Documenting clinical information in the electronic or other health record

• Independently interpreting results (not separately reported) and communication results to the patient/parent/caregiver

• Care coordination (not separately reported)

• Documented technical difficulties when trying to connect with a patient for a Telehealth visit

Doesn't Count

• Documentation done by clinical staff

• Scribe time

• Chart/visit preparation done prior to the date of the actual visit

• Documentation done on days after the visit

Suggestions
  • Give providers "prep time" in the morning before patient appointments begin for the day.
  • Give providers "catch-up time" throughout the day to catch up on their documentation so that their work does not extend outside of the date of the visit.
  • Delay choosing E/M code until later in the day in case more time is spent on the patient's Encounter after the patient leaves the office.

• Time spent doing work that is separately billable with its own CPT code, such as reviewing Vanderbilts or performing procedures

• Time of a "non-qualified" other healthcare professional that you supervise

• Time spent doing non-clinical work, such as scheduling an appointment

Where in OP Time is Tracked 

Tracked in the Encounter
Note: All sections of an Encounter are time-tracked except for Coding.
Tracked in the Patient Chart
Not Tracked in the Patient Chart

Note: Patient Messages created using the Send Message button in the Clinical and Practice Management tab are also counted time-tracked. 

- Schedule (Calendar or Tracking)*
- Message Center*
- Clinical Work window*
- Billing Center*

*While these areas can be used to navigate to a Patient Chart, the act of viewing these windows does not trigger time-tracking. It is not until you actually go to a time-tracked area that time-tracking begins.
Version 20.10
  Take me to all 2021 Office Visit E/M Coding Resources!

Important Note about the Development of these Features

It is important to note that the details of what “should” and “should not” count are evolving and the developments in OP can only align with what we know to be true at the time of development. We expect that there will be modifications to the enhancements as more is learned from both the industry and our practices. All coding recommendations are suggested based on information that can be tracked in OP.

" A reminder that time tracking is guidance only. It's meant to assist you and offer guidance. It should not be taken as gospel and absolutely accurate. It should be used as your sanity checker. It uses time tracking to offer coding recommendations but it is up to the Rendering provider to confirm accuracy and choose a code based on what actually happened." - Sue Kressly, MD, FAAP

Global Preferences to Consider with Time-Tracking

Time-tracking starts and stops depending on where in the system the provider is working with the patient focused on the date of the patient's Encounter (from 12:01AM - 11:59PM). Because of this fluid tracking, there are a couple of OP setup items that your practice may already have in place that will impact the accuracy of time-tracking for your providers. These settings are located in the Security tab of Global Preferences (Admin tab  Global Preferences > Security tab) and can be changed by a Practice Administrator, if necessary:

IFYour practice's OP is set up to log a user out of OP after a specific amount of time...THENTime-tracking will stop when the logout occurs. 
What this means: This is an important security feature and should not be disabled. However, this may lead to untracked-time spent with the patient. The provider will just need to be aware of this when confirming their Total Time during visit coding. Or, the practice can make a decision to increase the amount of time before the logout occurs.
IFYour practice's OP is set up to allow users to be logged-in on multiple workstations...THENTime-tracking will not be accurate for the visit. OP cannot keep track of time for a provider logged in on multiple workstations.
Do This: Navigate to the Security tab of Global Preferences and select the checkbox to disallow simultaneous login on multiple workstations.

Click the bullets below to learn more about Time-Tracking in the following sections:

Categorization of Time

Tracked-time is categorized into 3 buckets that are displayed for the provider during Encounter coding so that he or she can recall where their time was spent for the visit.

Pre-visit Preparation
Preparation that occurs before the patient is seen.
Intra-visit Work*
Work done by the provider during the visit.
Post-visit Work*
Work done by the provider after the visit.

* Your practice can decide the Visit Stage that categorizes the time-tracking into this bucket and make that setting in Global Preferences. Click here to learn how to set your practice's Intra-visit Work and Post-visit Work Visit Stages. If no setting is made, all time-tracking is displayed as Total Time, without categorization. This does not mean that time is not tracked. It simply means that it is not divided into buckets.

What Does and Does Not Count as Time for an Encounter

Counts

• Provider time spent logged into OP on the date of the patient's Encounter

• Reviewing tests in preparation of seeing the patient

• Obtaining and/or reviewing separately obtained History

• Performing a medically appropriate examination and/or evaluation

• Counseling and educating the patient/parent/caregiver

• Ordering Medications, Tests, or Procedures

• Referring and communication with out healthcare professionals (when not separately reported)

• Documenting clinical information in the electronic or other health record

• Independently interpreting results (not separately reported) and communication results to the patient/parent/caregiver

• Care coordination (not separately reported)

• Documented technical difficulties when trying to connect with a patient for a Telehealth visit

Doesn't Count

• Documentation done by clinical staff

• Scribe time

• Chart/visit preparation done prior to the date of the actual visit

• Documentation done on days after the visit

Suggestions
  • Give providers "prep time" in the morning before patient appointments begin for the day.
  • Give providers "catch-up time" throughout the day to catch up on their documentation so that their work does not extend outside of the date of the visit.
  • Delay choosing E/M code until later in the day in case more time is spent on the patient's Encounter after the patient leaves the office.

• Time spent doing work that is separately billable with its own CPT code, such as reviewing Vanderbilts or performing procedures

• Time of a "non-qualified" other healthcare professional that you supervise

• Time spent doing non-clinical work, such as scheduling an appointment

Where in OP Time is Tracked 

Tracked in the Encounter
Note: All sections are time-tracked.
Tracked in the Patient Chart
Not Tracked in the Patient Chart


- Schedule (Calendar or Tracking)*
- Message Center*
- Clinical Work window*
- Billing Center*

*While these areas can be used to navigate to a Patient Chart, the act of viewing these windows does not trigger time-tracking. It is not until you actually go to the Patient Chart that time-tracking begins.