Outpatient Facility Coding Alert - 2023 Issue 5
Reader Questions: Recognize When Time Need Not Be Consecutive
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Article Overview
This reader Q&A addresses a common evaluation and management coding question about how same-day time is counted when a provider performs work before, during, and after a patient encounter. It is aimed at coders and clinicians who need to understand the general time-based framework used in office and outpatient E/M documentation, including the post-2021 approach to time calculation and record support.
Why This Topic Matters
Understanding the time-based E/M framework helps prevent undercounting or miscounting provider work and supports documentation that can withstand audit review.
What You Will Learn
- How same-day time is generally counted for E/M services
- Why nonconsecutive work time may be included in the total
- What kinds of documentation support time-based E/M reporting
- How the current approach differs from older face-to-face-only assumptions
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Other clinicians documenting E/M services
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