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Per AMA and CMS guidance, it includes every qualifying activity the billing provider performs on the date of the encounter: Preparing to see the patient, including reviewing records and test results Obtaining and reviewing separately obtained history Performing the examination or evaluation Counseling and educating the patient and/or caregiver Ordering medications, tests, or procedures Communicating with other healthcare professionals when not separately reported Documenting clinical findings in the medical record Independently interpreting results and communicating them to the patient Coordinating care when not separately reported One thing to keep straight: only the billing provider's time counts

Jun 2 2025;105(6)doi:10.1093/ptj/pzaf057