In 2021, If selecting an E/M Office or other Outpatient code based on total time, what is the best practice for documentation, ie, documenting total time only or documenting face-to-face and non-face-to-face time separately? ...
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Article Overview
This article explains the documentation topic surrounding 2021 office and other outpatient E/M services when time is used for code selection. It addresses the general documentation purpose, notes that specific best practices are not spelled out in the guidelines, and highlights that payer policies may add their own requirements. The piece is relevant to coding professionals, billers, and clinicians who document evaluation and management services.
Why This Topic Matters
Accurate time documentation can affect whether an office or outpatient E/M service is supported under the 2021 guidelines, and payer-specific expectations may influence how records are maintained.
What You Will Learn
- How the 2021 E/M office and outpatient guidelines address time-based documentation
- Why documenting time in the health record matters when time drives code selection
- How payer-specific documentation expectations may affect recordkeeping
- What broad documentation considerations apply to office and outpatient E/M services
Who Should Read This
- Medical coders
- Billers
- Compliance staff
- Physicians and other clinicians
- Revenue cycle professionals
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