Mind the time rules: There are two ways of tracking time for E/M visits

Why This Topic Matters

Time documentation affects code selection, compliance, and payment accuracy. The article helps practices understand the difference between two time-tracking approaches and avoid software-driven errors in E/M coding workflows.

Article Sections

1. Updated time-based coding for office and other outpatient E/M visits

   Introduces the updated CPT time-based approach for office and other outpatient evaluation and management services. It also notes how this approach differs from time use in other E/M settings.

2. EHR and coding system risks

   Discusses how electronic health records and coding tools can create workflow risks when they prompt users to enter visit times. The section focuses on system design considerations for accurate time capture.

3. Counting time activities for office visits

   Summarizes broad categories of work that may contribute to total time in office-based E/M visits. It also notes that systems should allow time to be recorded by activity or as a total.

4. Day-of-encounter time limits

   Explains software safeguards related to when time may be counted for time-based office visits. The section addresses same-day encounter timing and reminders for staff.

5. Counseling/coordination of care rules unchanged

   Reviews the longstanding counseling and coordination of care framework for E/M services. It covers general documentation and time-counting concepts for settings where those rules still apply.

6. Software checks for setting-specific activity lists

   Notes an additional system check related to where a visit occurred. The section highlights the importance of matching activity lists to the correct encounter setting.