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Coding Based On Time
 

 
You may have noticed that there are “recommended” times for most, but not all E/M encounters.  This allotted time is merely a guide.  Some encounters may take longer than their allotted times, while others may take less than the time allowed.  It is NOT necessary to use the allotted time for any particular encounter if you are coding based on the documentation of the three key components.  In other words you are not penalized for being efficient.

However, the E/M guidelines do have a specific provision to allow physicians to use TIME as the controlling factor to determine the level of care in certain circumstances.   In these instances, the physician MUST spend the entire allotted time face-to-face with the patient AND at least HALF of that time must be used for “counseling and coordination of care.”  If you choose to code based on time, you MUST record the duration of the encounter in the record, AND also state that over half the time was spent on counseling and coordination of care.  In addition, the nature of the counseling and coordination of care must be documented. 

Example

You see a patient with dyslipidemia and borderline hypertension and discuss the rationale for treating high cholesterol with medications.  You spend a total of 15 minutes in the room with the patient discussing this issue.  If you want to code this encounter based solely on time, you would have to document something like this

CC: follow-up dyslipidemi

Interval history:  The patient is here to ask why he needs to stay on statin medication for cholesterol.     
Most recent LDL was 131

Exam: BP 144/90

Assessment
  1. Dyslipidemia
  2. Borderline hypertension
Plan
  1. Continue statin therapy
  2. Recheck blood pressure at next visit
  3. A total of 15 minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care.  We discussed in depth the importance of primary prevention of coronary disease with aggressive treatment of high cholesterol.  I also educated the patient about lifestyle modifications which may improve blood pressure
E/M Coding Tip: If you code based on time, there are NO SPECIFIC DOCUMENTATION REQUIRMENTS FOR HISTORY, PHYSICIAL EXAM AND MEDICAL DECISION MAKING.  It is recommended, however, that the physician record pertinent information about these items in the chart.  It is absolutely essential to record the time spent.
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