Watch the clock, documentation rules if you plan on time-based E/M coding in 2021

Why This Topic Matters

The article helps readers understand why accurate time documentation matters as office E/M reporting changes take effect and why incomplete or unsupported time reporting can create audit and compliance risk.

Article Sections

1. Coding

   Introduces the upcoming office E/M time-based coding changes and frames the compliance concerns discussed in the article.

2. Two cautionary cases

   Reviews recent legal and enforcement examples that illustrate the risks of unsupported time reporting in E/M billing.

3. Typical time out for office visits

   Summarizes how office visit time-based reporting is changing and what general timing concepts are discussed in relation to office E/M services.

4. Check the time, and activities

   Outlines the broad categories of work that may be considered in total time and discusses the importance of documenting activities performed on the date of service.

5. Watch possible timing errors

   Highlights common documentation and billing mistakes associated with time-based E/M reporting, including staffing, timing, and overlapping-service concerns.