E/M Coding: Start Using Time to Up E/M With These Tips

Why This Topic Matters

Accurate E/M level selection depends on the documentation framework used for the encounter. Understanding when time may be used, and what must be documented to support it, helps reduce undercoding, overcoding, and audit risk.

Article Sections

1. Verify Note Includes 3 Items

   This section outlines the broad documentation elements discussed for office-based E/M services when time is being considered as the controlling factor. It focuses on the kinds of information that need to appear in the note.

2. Go With HEM as Fall-Back Position

   This section describes the alternate approach when the documentation does not support time-based selection. It contrasts that fallback with the general documentation framework used for E/M coding.

3. Think Time for Counseling

   This section discusses situations in which counseling-oriented visits may be considered for time-based E/M coding. It includes a general illustrative scenario and references the broader counseling-focused nature of the guidance.