EM Coding Alert

Question: One of my colleagues has a habit of rounding up the time our provider spends with patients. I ran a brief internal audit and noticed that it appeared that one physician had been in the clinic for 13 straight hours, and when I looked at the encounters from that day, they were all suspiciously round numbers: 30 minutes, 20 minutes, 25 minutes. I’m worried that the coder is rounding up the encounters. Is this OK?

Michigan Subscriber

Answer: Adding an extra five minutes to each patient could end up looking like each physician spent hours longer at the clinic than they really did, which is maybe what happened here. Inflating time, whether intentional or not, is something practices should avoid, especially because it raises red flags during audits — even during internal audits.

Make sure your colleagues know to stick to observing what’s in the medical record and report encounters as they’re documented. You may want to plan a continuing education session and remind coders of their responsibilities and best practices, as well as going over (or establishing) a code of conduct for coding staff.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC