The CPT rules for the use of problem-oriented E/M office visit codes changed significantly on January 1, 2021. Since then, office visits are coded based on levels of medical decision-making or “total time” and the prior rules for using the “three key components” no longer apply. Consequently, Family PACT E/M coding policies were updated in February 2021, as well as the publication of a new policy on coding and billing for counselor services.

Learning Objectives:

  1. List at least six activities that can be counted in the “total time” of a visit when computing E/M level
  2. List each of the 3 elements used in medical decision-making, and give examples of each
  3. Describe the Family PACT policy for coding for a clinician visit and counselor services on the same date of service


  • Michael Policar, MD, MPH