One of the most common challenges with E&M coding is whether to follow the traditional guidelines or to code a patient encounter based on time. Though it may seem like cheating, official rules allow for medical professionals to skip the documentation of the standard three E&M coding components (history, physical exam, and medical decision-making) as long as a few specific standards are met.
For starters, physicians can only code based on time if the entire encounter is done face-to-face, meaning that online or phone consultations must be coded traditionally. Furthermore, the patient encounter must consist of at least 50% counseling. In other words, if more time is spent on the physical examination than on recommending treatment or future actions, then the visit does not qualify. If these criteria are met and the physician decides to code based on time, then he or she should be sure to include the full visit time, as well as a note specifying that at least half of the encounter was spent on counseling.
Keep in mind, however, that while the time standard for E&M coding does not technically have any requirements for patient history or physical exam notes, it is still vital to include at least an overview of this information. In the event of a complication or audit, these additional notes will contain important info that would otherwise be lost. In other words, it is always best to play it safe, even if the documentation requires a few extra minutes.
Additionally, medical professionals should remember that the total duration of the encounter MUST be recorded. Even if additional notes are included, the documentation will always be invalid unless the time is included. On top of that, physicians should keep in mind that they will need to keep track of the visit length more accurately when coding based on time. While encounter times can be rounded when coding with the three traditional components, time-based coding requires that duration be recorded down to the minute, as these codes change more frequently with the total time taken.
All in all, time-based E&M coding is an excellent way shortcut for documenting simple encounters. As long as physicians make sure to keep an eye on the clock, this method of coding will keep reports short and sweet.