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

Why This Topic Matters

Time-based E/M reporting can be easier to use but also easier to miscoded if documentation is incomplete or if noncountable time is included. Understanding the updated guidance helps organizations reduce claim denials, audit exposure, and false claims risk.

Article Sections

1. Two cautionary cases

   Examples of enforcement and audit concerns tied to E/M time reporting and visit-level coding patterns.

2. Typical time for office visits

   Overview of the office/outpatient E/M timing framework, including the general shift to time-based reporting under the updated guidelines.

3. Check the time, and activities

   Discussion of the broad categories of work that may be counted toward total time and an illustrative time-accounting example.

4. Watch possible timing errors

   Common documentation and timing pitfalls that practices are warned to avoid when supporting time-based E/M coding.