BC Advantage - 2015 Issue 9

Time-Based Services

How many of you have been under the impression that if time is used as the controlling factor in E/M code assignment, that the "key components" (history, exam, and mdm) are not necessary to consider? Most of us were, but this is not technically correct according to CMS. CMS Guidance states (found in the .pdf document download on page 4, section c): "In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction...

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