CPT Knowledge Base - Jun 17, 2015
How do we determine when to use time when coding E/M services? ...
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Article Overview
This short coding guidance article addresses the use of time in evaluation and management (E/M) service selection. It is aimed at coders, billers, and clinicians who document office, outpatient, hospital, or nursing-facility encounters and want to understand the general circumstances under which time becomes the key factor. The article also notes the importance of documenting counseling and coordination of care in the medical record.
Why This Topic Matters
Accurate E/M level selection depends on recognizing when time may be used instead of other components. Clear documentation supports compliant code assignment and helps reduce coding errors.
What You Will Learn
- When time may be considered the controlling factor in E/M service selection
- What types of encounter time are referenced in general terms
- Why documentation of counseling and coordination of care matters for time-based coding
- How a time-based example is used to illustrate E/M level selection
Who Should Read This
- Medical coders
- Billers
- Physicians
- Nurse practitioners
- Physician assistants
- Clinical documentation staff
Codes Discussed
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