If I want to code E/M based on time is mandatory the note form Dr stating "time face to face with patient was 30 minutes" ? My doubt is because I have some reports that has for example 10:am in vital sings and 10:40am at the bottom in the Dr signature and that can be 40 minutes encounter; however, the Dr didn't specify the time face to face with pt.
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki E/M BASED ON TIME. PLEASE HELP ASAP. THANK YOU
- Thread starter patry88107@gmail.com
- Start date
You cannot code an E/M based on time if the doctor didn't document it.
AMA reference https://www.ama-assn.org/system/files/regulatory-myths-doc-coding-em.pdf
Last edited:
jkyles
True Blue
- Messages
- 933
- Best answers
- 1
Agreed. While I've yet to see official guidelines from CMS on how to document time beyond that you can use total time or start/stop time, the provider must still follow general guidelines for documenting encounters.
You can't just go by the EMR time. In this example, vitals are usually performed by clinical staff and you can't count clinical staff time toward the visit. The best and (most practical) practice that I've seen is to document as they would for MDM and add their total time.
Also I'm going get on my time-based E/M soap box
for a moment: Providers can get credit for certain non-face-to-face activities related to the patient's visit on the date of the face-to-face encounter. There's a list in the CPT Manual. If providers only document and count their face-to-face time the record might be incomplete and they could miss out on full credit for their work.
You can't just go by the EMR time. In this example, vitals are usually performed by clinical staff and you can't count clinical staff time toward the visit. The best and (most practical) practice that I've seen is to document as they would for MDM and add their total time.
Also I'm going get on my time-based E/M soap box
for a moment: Providers can get credit for certain non-face-to-face activities related to the patient's visit on the date of the face-to-face encounter. There's a list in the CPT Manual. If providers only document and count their face-to-face time the record might be incomplete and they could miss out on full credit for their work.