decisionhealth Newsletters, Part B News - 2015 Issue 8 (August)
Document correct language, exact time before billing time-based E/M
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Article Overview
This piece is for physicians, coders, and revenue cycle staff who document evaluation and management services and want to understand what supporting information is needed for time-based billing. It discusses broad documentation elements, patient presence, timing language, and setting-related considerations that affect whether a time-based E/M claim is supportable. The article is focused on practical compliance documentation themes rather than code selection details.
Why This Topic Matters
Accurate documentation is essential when billing time-based E/M services because incomplete or unclear time statements can create compliance risk or missed reimbursement opportunities. The article helps readers recognize the general documentation components expected for this type of service.
What You Will Learn
- What general documentation elements are associated with time-based E/M billing
- How timing and counseling/coordination-of-care language are described in a patient encounter
- Why patient presence and the care setting matter for this type of documentation
- What broad compliance concerns may arise when time-based coding is used frequently
Who Should Read This
- Physicians
- Coders
- Billing staff
- Revenue cycle professionals
- Compliance staff
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