Part B Insider - 2020 Issue 1
You Be the Coder: Take Time to Code This E/M Encounter by the Book
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Article Overview
This Q&A article explains documentation issues involved in reporting a new patient office/outpatient evaluation and management visit when time is used to support code selection. It is intended for coders and clinical documentation staff who need to understand general E/M time requirements, counseling documentation expectations, and the relationship between time-based selection and component-based medical necessity review.
Why This Topic Matters
Accurate E/M documentation affects code selection, compliance, and the ability to support the reported level of service. The article helps readers recognize when a note may need additional specificity before a time-based office visit code can be supported.
Article Sections
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Question
The opening question presents a documentation scenario involving a new patient office/outpatient E/M encounter and asks whether the record is sufficient to support reporting based on time.
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Answer
The answer discusses general principles for selecting a new patient office/outpatient E/M service when time is used and describes documentation considerations for counseling and overall support of the reported level.
What You Will Learn
- How time-based selection is discussed for a new patient office/outpatient E/M encounter
- What types of documentation specificity are emphasized for counseling when time supports code selection
- How documentation may alternatively support a code level through E/M components and medical necessity review
- What kinds of record elements coders should confirm before reporting a time-based office visit service
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Physician practices
- Billing staff
Codes Discussed
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