Take time to review your MAC’s requirements for recording E/M time

Why This Topic Matters

Time-based E/M documentation remains an area of audit sensitivity, and this article helps readers understand the broad documentation expectations discussed by CMS and MACs so they can assess whether their records and internal review practices are aligned with current guidance.

Article Sections

1. Coding

   Introduces the topic and frames the documentation concerns surrounding time-based evaluation and management services.

2. Check your MAC for help

   Summarizes general guidance from CMS and several Medicare administrative contractors on recording and supporting time in the medical record.

3. Ask treating clinicians to collaborate

   Discusses internal collaboration, chart review, and compliance processes for comparing provider documentation practices and building a shared organizational approach.

4. Resources

   Lists external reference materials and agency resources cited in the article.