Outpatient Facility Coding Alert - 2019 Issue 9
Guidelines: Take Time to Code Your E/M Encounters
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Article Overview
This guide explains the general requirements and documentation elements involved in time-based evaluation and management coding. It is aimed at coders and clinicians who need a clearer understanding of how encounter time is documented, what supporting record elements matter, and why incomplete documentation can affect code reporting. The article also highlights common mistakes seen in real-world encounter notes and record timestamps.
Why This Topic Matters
Accurate time-based E/M coding depends on documentation quality. Understanding the documentation expectations helps support compliant reporting and reduce errors when encounter time is used as the basis for code selection.
Article Sections
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Get the Background Info
Introduces the general concept of time-based E/M coding and the documentation context discussed in the guide.
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Documentation Is in the Details
Summarizes the kinds of record information the article says should be present when time-based E/M coding is used.
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Know What Not to Do
Reviews common documentation problems and recordkeeping issues discussed in the article.
What You Will Learn
- The general basis for using time in E/M visit coding
- What documentation elements are discussed for supporting encounter time
- Why record timestamps may differ from documented total time
- Common documentation pitfalls related to time-based E/M encounters
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and clinicians
- Practice managers
- Health information management professionals
Codes Discussed
Code Ranges Discussed
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