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.
Your coding questions answered.
www.physicianspractice.com
"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)
