Part B Insider - 2023 Issue 11
You Be The Coder: Rely on Documentation for Test Review
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Article Overview
This premium coding Q&A addresses a common documentation question about whether prior test review can be counted again during later evaluation and management services. It is aimed at coders, billers, and clinicians who work with CPT time-based E/M reporting and need to understand the kinds of physician work that may be considered in total time, along with the importance of documentation and payer variation.
Why This Topic Matters
Accurate time reporting affects E/M code selection and compliance. The article helps readers understand how documentation supports counting certain activities while recognizing that payer policies may differ.
Article Sections
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Question
A coding scenario involving follow-up review of prior procedure findings during an office visit and whether that work may be considered in visit time.
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Answer
General CPT time-based E/M guidance on the types of physician work that may count toward total time, along with a reminder about documentation and possible payer-specific limitations.
What You Will Learn
- How time-based E/M concepts relate to review of prior findings
- Which broad categories of physician work may be considered in total time
- Why documentation matters when revisiting previously reviewed information
- How payer policy may affect whether time can be counted
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Other qualified health care professionals
- Compliance teams
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