Gastroenterology Coding Alert

Question: If we’re selecting an E/M level of service (99202-99215) based on medical decision making (MDM), do we still have to document the amount of time spent during the encounter?

Georgia Subscriber

Answer: No, you don’t have to document the time spent, although it may still be a good idea.

Here’s why: Under the 2021 E/M guidelines, you can select the outpatient E/M level based on either time or MDM, and if you choose to go the MDM route, you don’t need to have time documented in the chart. However, it can be a good idea to get into the habit of documenting time, because in some cases, you may find that the documented MDM doesn’t add up to the level required to bill the E/M code describing the service that the physician believes took place. In these situations, you can check the time documented to see if that would support the level of service instead, providing you with a wider range of options to select the code. Note that the time is not restricted to time spent during the encounter, but the entire calendar day of the encounter for work on behalf of that patient.