I agree with the advice, I would just caution, if every note has time in it and the provider is routinely stating a time much lower than the code level by MDM it "could" cause issues. I would just leave the time out unless the provider wanted to code by time. It's just not a great practice (in my opinion) to list the time in every single note unless the E/M is being chosen by it. Basically, if coding by time list that, if not leave it out.
I get that experienced providers may be quicker and the MDM could be high even if it doesn't take long, I am just pointing it out from an auditing perspective.
Providers also have to be careful of impossible time where the total schedule or hours worked per day doesn't align with the total time documented for patients that day.
Maximize payment and reduce stress by understanding how to properly document and code for evaluation and management (E/M) services.
www.aafp.org
How do I know which method (MDM or total time) to use to select the level of visit?
There’s no specific guidance to determine which method to use. You should use the method that most appropriately captures the work performed during the encounter. For example, for an encounter during which the patient had many questions and the level of MDM was lower, it may make more sense to select the level of service using time. Conversely, if an encounter was brief but required a higher level of MDM, it may be appropriate to select the level of service using MDM. Whichever method you use, include sufficient documentation to justify the level of service billed. Additionally,
document based only on the method you used; do not document both time and MDM for the same encounter, because this could confuse auditors.
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Don’t use time spent to support every single E/M visit. This may be controversial, or even unwelcome advice for some physicians, but I continue to take the view that providers should code a visit based on time only when that visit is taking longer than usual, whether due to counseling, coordination of care, preparing for the visit by finding and reviewing old records, or some other reason provided for in the CPT guidelines. With good documentation, the MDM will support a higher level of service without needing to count time.
Indeed, to begin documenting time on each visit poses its own level of risk, especially if the practice also uses non-physician practitioners (NPP) and incident-to billing."
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