Part B Insider - 2019 Issue 8
Reader Question: Improve Your E/M Time Coding Accuracy
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Article Overview
This article addresses a common documentation question about evaluation and management services billed by time. It is aimed at coders, billers, and clinicians who need a clearer understanding of how time should be reflected in the record across office/outpatient and inpatient settings, and what general documentation elements are emphasized for time-based E/M reporting.
Why This Topic Matters
Time-based E/M billing is documentation-sensitive, and uncertainty about what must be recorded can create claim risk. The article helps readers understand the broader documentation expectations relevant to time reporting without replacing the underlying coding guidance.
What You Will Learn
- How time-based E/M documentation is discussed in a Q&A format
- How time is treated differently in office/outpatient versus inpatient settings
- What general documentation elements are emphasized when time is used for E/M reporting
- How counseling and coordination of care factor into time-based visit reporting
Who Should Read This
- Medical coders
- Medical billers
- Physicians
- Clinical documentation staff
- Practice managers
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