General Surgery Coding Alert - 2016 Issue 3
You Be the Coder: Using Time to Choose E/M Level
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Article Overview
This short coding Q&A discusses when time-based selection may be used for an established patient office or outpatient E/M visit when the usual documentation supports a lower level. It is aimed at medical coders and billing staff who need to understand the relationship between counseling, time, and E/M level selection, along with the related diagnosis coding context.
Why This Topic Matters
Accurate E/M level selection affects claim reporting and documentation alignment. The article helps readers recognize when time-based guidance may be relevant for office/outpatient visits and how the diagnosis is represented on the claim.
What You Will Learn
- How counseling and encounter time relate to office/outpatient E/M level selection
- How a diabetes diagnosis is represented in the example
- How time-based documentation considerations are discussed in an established patient visit scenario
- How a lower-supported service level can differ from the reported level when time is used
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Practice managers
- Compliance staff
Codes Discussed
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