tci E/M Coding Alert - 2019 Issue Q4

Reader Question: Take the Time to Document Correctly

Question: I’m confused about coding E/M services by time. Do we have to document the exact amount of time spent on counseling and coordination of care, and do we have to document how much face-to-face time the physician spends with the patient? Alabama Subscriber Answer: To bill an E/M visit based on time, you must document that the majority of the time was spent in counseling and coordination of care. For the office/outpatient setting, only face-to-face time counts toward the total time spent, but for the inpatient setting, you should also count time spent on the unit focused...

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