General Surgery Coding Alert - 2017 Issue 7
Reader Question: Use Time as Dominant Factor
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Article Overview
This article addresses a common office-visit coding question involving time-based evaluation and management reporting when counseling is the main focus of the encounter. It is written for coders, billing staff, and clinicians who need a general understanding of when visit time may be used, what documentation is expected, and how CPT guidance frames these situations. The discussion is centered on outpatient E/M reporting and includes a brief example to illustrate the topic.
Why This Topic Matters
Encounters where counseling dominates can affect how an office visit is reported and documented. Understanding the general framework helps practices support compliant E/M coding and recognize when CPT time guidance is relevant.
What You Will Learn
- How time may be considered in office and other outpatient evaluation and management visits
- Why counseling and coordination of care documentation matters
- How CPT guidance relates to established patient visit reporting
- General considerations for face-to-face encounters versus non-face-to-face discussions
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Practice managers
Codes Discussed
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