Coding Strategies: Take These Steps to Ensure Your Time Documentation Makes the Grade

Why This Topic Matters

Accurate time documentation can affect whether an E/M service is coded from time or from the documented history, exam, and medical decision-making. The article highlights why incomplete records may lead to downcoding or audit risk and why clear counseling and coordination-of-care documentation matters.

Article Sections

1. Background

   Introduces the role of auditors in reviewing E/M claims and explains the general relationship between documentation and code selection.

2. Myth

   Presents a common belief about using counseling time to support higher-level office visit coding.

3. Reality

   Explains the documentation issue that arises when time is not clearly recorded in the chart.

4. Case in point

   Reviews a sample patient note to illustrate how documentation is evaluated when time and counseling details are incomplete.

5. Step 1: Include 3 Items in Documentation

   Outlines the documentation components that should be present before time is used as the controlling factor for coding.

6. Step 2: Use Elements When Time is Unknown

   Shows how the visit is considered when counseling time is not documented and the usual E/M elements are used instead.

7. Solution

   Summarizes the documentation change that would affect whether time-based coding could be supported.