Tips to time your services just right when reporting time-based codes

Why This Topic Matters

Accurate time documentation can affect whether time-based services are paid as submitted, reduced, or denied. The article is relevant for practices that bill E/M services and other time-dependent services and want to align documentation with Medicare review expectations.

Article Sections

1. Documenting time for time-based services

   Discusses the importance of recording time consistently and describes general approaches to documenting duration in medical records. It also introduces concerns raised by Medicare review activity.

2. What time can and cannot be counted

   Covers broad distinctions between time that may be counted and time that should be excluded in different care settings. The section compares office or outpatient documentation with hospital observation or inpatient documentation.

3. Counseling and coordination of care in E/M services

   Summarizes how counseling or coordination of care can affect evaluation and management reporting. It also notes that contractors may request additional documentation when these services are billed based on time.

4. Typical cardiology scenarios

   Describes common clinical situations in cardiology where time-based reporting may come into play. The examples are presented at a high level and relate to several practice settings.

5. Additional time-based coding points

   Reviews other general considerations tied to time-based coding, including who may contribute time and how certain services are evaluated. The section also mentions Medicare contractor guidance and official reference materials.