Pediatric Coding Alert

Keeping your eyes on the clock isn’t the only rule to follow.

When you code an evaluation and management (E/M) service, you know you sometimes have a choice to code the components of the service — the history, physical examination, and medical decision-making involved — or code by the amount of time your provider spent with the patient.

But do you know when you should code using time? Moreover, do you know what documentation you’ll need if you do code by time, or whether you can code nonphysician provider (NPP) services this way? Whether you’re new to the challenges of E/M coding, or you need a refresher, here are four questions for you to answer that will help you sharpen this basic coding skill.

Question 1:
When should I code based on time?

Question 2:
If I code based on time, what documentation do I need?

Question 3:
An NPP in our practice provided counseling to a patient’s foster parents. Can I use time-based reporting to record the E/M service?

Question 4:
My provider spent 40 minutes face-to-face with a patient and reported spending 15 minutes counseling the patient. What E/M code should I use?

Think you know the answers?