decisionhealth Newsletters, Coder Pink Sheets - 2022 Issue 1 (January)
Office E/M: Time-based coding can’t be based on best guesses or estimates
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Article Overview
This premium coding article discusses office E/M documentation and time-based code selection for outpatient visits. It is aimed at coders, billing staff, and providers who document office encounters and need to understand what kinds of work can be counted, how documentation affects code selection, and why estimates or averages are not enough. The article also places the discussion in the context of selecting between time and medical decision-making for office visit coding.
Why This Topic Matters
Accurate time documentation affects office E/M code selection and charge capture. The article helps readers understand the general documentation expectations involved in counting work performed on the date of service without relying on unsupported assumptions.
What You Will Learn
- How office E/M time-based coding is discussed in relation to encounter documentation
- What kinds of documentation support time-based code selection at a high level
- Why documented time matters for outpatient visit coding
- How providers and practices may think about time-based coding versus medical decision-making
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Physicians and non-physician practitioners
Codes Discussed
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