tci E/M Coding Alert - 2019 Issue Q4

Reader Question: Document Necessity, Not Elements, When Levelling by Time

Question: If I am billing an E/M encounter by time, does documentation for the E/M elements have to be in the record, or can the E/M level be determined solely on the provider’s documentation of the time spent in counseling with the patient? Arkansas Subscriber Answer: Most coders are trained to look in the record for the elements — the history, exam, and medical decision making (MDM) — then compare the level of E/M that they create with the time the provider spends in counseling. If, as most often happens, the counseling time leads to a higher-level E/M...

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