Outpatient Facility Coding Alert - 2014 Issue 42
Reader Question: Accurately Calculate Time Spent
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Article Overview
This reader Q&A addresses time accounting for an office/outpatient evaluation and management encounter when an additional procedure occurs during the visit. It is aimed at coders, billers, and clinical documentation staff who need to understand how encounter time should be documented and reported in general terms. The article also touches on counseling documentation and selecting an appropriate visit level based on time.
Why This Topic Matters
Time-based E/M reporting depends on accurate documentation of the time actually attributable to the visit. This topic is important because procedure time occurring during the encounter may affect how total time and counseling time are recorded.
What You Will Learn
- How time-based reporting is discussed for an office/outpatient evaluation and management encounter
- How documentation can distinguish overall encounter time from counseling time
- Why procedure-related time during the same encounter may need separate consideration
- What kinds of counseling topics may be documented in support of the visit time
- How visit level selection is discussed in relation to recorded time
Who Should Read This
- Medical coders
- Billing staff
- Clinical documentation specialists
- Physician office staff
Codes Discussed
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