BC Advantage - 2022 Issue 1

Auditing Time-Based E/Ms Under 2021 Guidelines

The 2021 E/M guidelines' more permissive rules for time-based coding is a potential watershed moment for physicians who want to spend less of their time documenting E/M notes. But if we interpret these changes to mean that the longstanding concept of "medical necessity" can be ignored whenever physicians record the number of minutes they spent, the resulting documentation will be a ticking compliance time bomb.In this article, I will argue that medical necessity must remain a consideration for auditors when they review E/M documentation and pivot to discuss how auditors should educate providers on what has – and...

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