Q&A: Best practices in time documentation

Article Overview

This article discusses general best practices for documenting physician time in a way that supports evaluation and management coding review. It is aimed at coders, auditors, and providers who need to understand common documentation approaches for time-based services and how those records are typically interpreted in auditing contexts. The discussion is framed around CPT and includes practical documentation themes such as capturing the span of care and clarifying how time was spent.