CPT® 2023: Sidestep 4 Pitfalls When Reporting E/M by Time

Why This Topic Matters

Time-based E/M reporting affects claim accuracy, compliance, and reimbursement. Understanding the updated scope of reportable activities and common audit triggers can help practices reduce denials, avoid overstatement of time, and support defensible documentation.

Article Sections

1. Clarify Which Activities Count Toward Time

   This section outlines the general categories of work that may contribute to total E/M time under the 2023 CPT® guidance. It also addresses documentation expectations for recording time on the date of service.

2. Avoid 4 Traps That Auditors See as Red Flags

   This section summarizes several common reporting mistakes associated with time-based E/M coding. It discusses audit concerns, shared or split visit considerations, and documentation issues that can affect claim support.

3. Pitfall 1— rounding up

   This subsection discusses concerns related to estimating or inflating time and why inconsistent time entries may raise audit questions.

4. Pitfall 2 — counting others’ time

   This subsection covers time attribution issues when multiple clinicians are involved in the encounter and references shared or split visit considerations.

5. Pitfall 3 — neglecting services

   This subsection addresses missing eligible work from the time total and the importance of documenting same-day activities that support the reported level.

6. Pitfall 4 — double counting services

   This subsection focuses on avoiding duplicate time reporting when another billable service is performed on the same date.

7. Takeaway: Be Confident About Time-Based Leveling

   This closing section emphasizes the importance of precise documentation and consistency when using time to support E/M leveling. It also notes how auditors may compare reported time against the overall workday.