Medicare Compliance & Reimbursement - 2019 Issue 10
Reader Question: Take the Time to Document Correctly
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Article Overview
This article explains general documentation considerations for time-based evaluation and management services. It is aimed at coders and providers who need to understand what kinds of time documentation are relevant in office/outpatient and inpatient settings, and it focuses on broad documentation expectations for counseling and coordination of care without delving into code-specific guidance.
Why This Topic Matters
Accurate time documentation affects whether an E/M service can be supported when time is used as the basis for reporting. The article helps readers understand the difference between office/outpatient and inpatient time counting in a general, non-code-specific way.
What You Will Learn
- How time-based E/M documentation is described in general terms
- How documentation expectations differ between office/outpatient and inpatient settings
- What broad time statements are discussed for counseling and coordination of care
- How face-to-face time relates to office/outpatient documentation
Who Should Read This
- Medical coders
- Physicians
- Billing staff
- Compliance staff
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