Wiki Documented times vs Documented MDM

[dsbynum@arkbluecross.com]

If the time spent with the patient is documented does that take precedence over any medical decision making documentation? Or does it get coded at whichever level is higher? I may be searching wrong or asking my question wrong because I can't seem to find this answer anywhere.

 

[ZubairHameed]

The CPT E/M guidelines for office and outpatient visits do not express a preference between using MDM or time. Rather, the choice of method, as well as the code-level determination, should correspond to the time spent and the complexity of care provided for the patient’s presenting issues. As such, the code-level selection is dictated entirely by the visit's context. If MDM justifies a higher-level code, billing at that level would be appropriate.

Thanks.

 

[jkyles]

If the time spent with the patient is documented does that take precedence over any medical decision making documentation? Or does it get coded at whichever level is higher? I may be searching wrong or asking my question wrong because I can't seem to find this answer anywhere.

I would just add that if the provider is only counting time spent with the patient they could be missing out on revenue. They can count time for actions related to the patient's care on the date of the face-to-face encounter. See your CPT manual for details.

 

[ZubairHameed]

I would just add that if the provider is only counting time spent with the patient they could be missing out on revenue. They can count time for actions related to the patient's care on the date of the face-to-face encounter. See your CPT manual for details.

Exactly, this is very true as "The total time for E/M services performed on the date of the encounter" is used for time based selection of codes as per AMA CPT E/M guidelines by AMA Page #6 .

 

[amyjph]

It is whichever the provided intended to code by. They can choose MDM or time. If you see time documented, yet if you coded it by the MDM documented they would get a higher level, you would probably want to use MDM. If you are the coder you would want to code to whichever is more beneficial. But, if you constantly see the time says 10 minutes yet the documentation of MDM would support a level 4 (mod/mod/mod) for example, you probably want to advise the provider not to document time UNLESS they actually want the note coded by time. Many EMRs auto-populate time or providers may incorrectly think they have to add it to every note. Not good.
If every single note has time and it doesn't match up with the documentation/complexity, that is going to be a flag for auditors most likely. And, if the provider is consistently documenting the exact same amount of time for every patient yet the coding should be higher/lower this is also a flag. Read the CPT E/M guidelines.

It is not recommended that time be documented in every single note unless the provider specifically intended to code by time. Or, unless the code being reported must have start and stop times documented. Some EMRs pull in appointment arrival and departure times but this is not the same thing.

There are many specialties where time makes more sense and you would expect to see that the notes are mostly coded by time. In other specialties, it would not make sense. Think about what type of visits you are coding. Talk to your providers about it. In general, one would expect to see a mix of both.

Some references but some are not "official" just info.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

E/M Level when time and MDM are documented

Your coding questions answered.

www.physicianspractice.com

https://codingintel.com/when-to-use-time-to-select-an-office-visit-code/

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management.html#totaltime

https://www.pracfirst.com/article/mdm-vs-time-based/

"Select the appropriate level of E/M services based on the following: 1. The level of the MDM as defined for each service, or 2. The total time for E/M services performed on the date of the encounter." ~CPT® Evaluation and Management (E/M)

 

[jkyles]

The other issue with time is I've yet to see a detailed regulation or payer policy for documenting time. CMS has a very vague statement that amounts to "We'll decide what's enough."

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104C12.pdf

G. Medical Review When Practitioners Use Time to Select Visit Level

Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to
support the E/M visit.

Or maybe they're saying "Do ya feel lucky?"