Gastroenterology Coding Alert

Question: My provider didn’t have time to write all the notes in a patient’s medical record right after the encounter and waited until the following morning. They said they want to report the evaluation and management (E/M) using time, and that the following morning’s record keeping needs to count toward the time spent during the encounter the day before. Can we do that?

Ohio Subscriber

Answer: No. To level the E/M using time, all that time has to occur during the same day as the encounter. Some providers feel they don’t have time to document the medical record during or right after the encounter and may wait until later to fill out their charts. But that’s not the best idea.

Total time, as it’s explained by CPT^®, includes face-to-face time in addition to time the physician personally spends on the patient’s care on the day of the encounter. You cannot include time spent on a different day.

Best practice: Healthcare providers are busy, but an accurate medical record is important. The more time that goes by, the less detailed the record will be. It’s best to document the encounter when it’s fresh in the memory. Important details can otherwise go unrecorded, and the forgotten details could very well be the difference between a correctly documented service and one that doesn’t even support the service(s) that is billed.