E/M 2021: Watch the time: There are two ways to track time for E/M visits

Why This Topic Matters

Time handling affects E/M code selection, documentation accuracy, and system workflow design. The article helps readers recognize how EHR prompts and coding tools can create risk in office and other E/M visit coding.

Article Sections

1. Time-based coding for E/M visits

   Introduces the updated time-based approach for office and outpatient E/M services and contrasts it with time-based concepts used in other E/M settings. Also discusses the importance of aligning staff education and software behavior with current guidance.

2. Software and EHR workflow considerations

   Describes potential documentation and billing risks created by EHR prompts, session timing workflows, and add-on code triggers. Focuses on software design considerations for accurate time capture and staff training.

3. Counseling and coordination of care rules unchanged

   Summarizes long-standing counseling and coordination of care time concepts for non-office E/M services and reminds readers to verify documentation practices across settings.