May 12, 2023 | By Scott Kraft, CPMA, CPC
The E/M Documentation Guidelines implemented in 2021 essentially place, time and medical decision making on equal footing. When visit time is documented, the service can be coded based on whichever of time and medical decision making is most favorable to the provider.
This has led many providers to ask a question – should I just code the time for every encounter? I usually say no – code the service time when it is the component you plan to use for billing.
Here are the reasons why:
- When time is in every note, if it is not the provider’s intent to make a code selection based on time, the presence of the time can be confusing to coders and auditors when the assigned code based on medical decision making is lower than what could be supported by the time.
- Time often feels imprecise in documentation. There are many reasons to that, but when coding based on time, providers often use the same time amount or amounts for every patient. Repeated across every single encounter, the exact same time and the exact same time statement could arouse needless suspicion for the pattern of the billing.
- Time statements when created as a MACRO may include items that are not part of every visit, raising the risks of including a time statement – even inadvertently – that doesn’t reflect the actual work that is done.
The documentation of service time should be a deliberate and thoughtful act by the provider to help support the medical necessity of the service as it is rendered and should be a precise measure of the amount of time that was spent on the patient’s care on the date of the face-to-face encounter.
As noted earlier, it is far too statistically unlikely that the volume of services documented as being precisely 30 or 40 minutes is an accurate reflection of the actual time that is spent – that is a compliance risk in itself.
Coding time in every encounter exposes the provider to concerns that he or she may be documenting more time than they actually spent on patient care on a calendar date or further expose the unlikelihood that the time is fully accurate in every encounter.
Remember, a time attestation carries the same penalties for false reporting as anything else in the claim. It should be used judiciously and recorded accurately.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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