E/M Coding: Yes, You Can Report E/M Codes When Talking to Family About Patient Care

Why This Topic Matters

It helps practices determine when family care discussions may be included in time-based E/M services and what documentation must support the claim under Medicare rules.

Article Sections

1. Watch the Clock

   Introduces time-based E/M reporting when counseling or coordination of care is the main focus of the encounter. It also summarizes the role of CMS and CPT in defining face-to-face time.

2. Consider These Examples

   Presents sample patient scenarios showing how time-based reporting may be discussed across outpatient and hospital settings. The examples are used to illustrate documentation and coding considerations.

3. Ensure Crystal Clear Documentation

   Reviews the types of documentation expected when time is used as the controlling factor for E/M selection. It emphasizes recording the visit time, the counseling component, and a summary of the care discussion.

4. What If the Patient Isn’t Present?

   Addresses Medicare’s patient-presence requirement and contrasts it with broader CPT language. It also notes documentation and medical-necessity concerns when family members meet with the clinician without the patient.