decisionhealth Newsletters, Coder Pink Sheets - 2012 Issue 9 (September)
Understanding E/M - Documenting time spent counseling patients is one route to better E/M reimbursement
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Article Overview
This article explains how evaluation and management documentation can affect reimbursement when counseling or coordination of care takes a significant portion of the visit. It is aimed at physicians, coders, and practice staff who want to improve documentation quality, recognize when time may support a higher service level, and identify other commonly overlooked billing opportunities discussed in the context of office and related services.
Why This Topic Matters
Accurate documentation can help practices capture legitimate reimbursement for time-intensive encounters and avoid leaving revenue unbilled. The article also highlights related areas where services may be overlooked if documentation and billing checks are incomplete.
What You Will Learn
- How counseling and coordination of care relate to time-based evaluation and management reporting
- What kinds of visit activities may be documented as counseling
- Why accurate time documentation matters for reimbursement
- Common areas where practices may miss additional billable services during a visit
- General documentation practices that help support billing review
Who Should Read This
- Physicians
- Coders
- Billing staff
- Practice managers
- Compliance staff
Codes Discussed
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