Time-Based E/m Codes: Document Your Way To Success

One way to pep up your medical coding career is to ethically maximize your practice's revenue while one place to look for cash is time-based E/M codes.

Lowballing time-based E/M codes because of poor documentation brings down revenue for many practices. Read on for some tips on time-based coding:

a) Document all times exactly. The most important part of coding by time is having complete and adequate documentation of the visit, which includes documentation of the total visit time and the total time the physician spends counseling.

b) Place a clock on the examining room wall so that it reminds the doctor to document time.

c) But if your doctor doesn't include enough documentation about counseling or coordination of care during the patient's visit, you may have no other alternatives but to code a lower-level E/M service. The minimum necessary documentation includes total time and what was addressed during the counseling/coordination of care. Although having start and stop times is better, the total time will also suffice. The individual payer will have to determine, upon audit, whether it'll accept total times contrary to the better documentation of start and stop times.

d) Remember that Inpatient time is different from outpatient time. The Evaluation and Management Service Guide on Medicare Learning Network restates that time in the hospital or nursing facility is floor/unit time while time in the office or outpatient setting is face to face time. This is a key distinction.

e) Do not forget your E/M basics. The physician should include the components of history, exam and MDM in the documentation.