Point Providers to E/M Differences
Question: A provider asked whether they can adjust their evaluation and management (E/M) coding to account for spending more time with a nervous patient. The provider asked specifically about time-based coding but also mentioned accommodating the patient’s nervousness. Does a patient’s demeanor play into time-based leveling calculations? AAPC Forum Participant Answer: If your provider is using time to select the appropriate E/M code, then they should be counting time and not including elements of other means of calculating E/M levels, like medical complexity. You can remind the provider to document the time they spend providing patient care: time with the patient face to face, as well as any time spent, for example, reviewing charts, clinical labs/tests/procedures/services, or counseling/education a patient about medication management, says Pam Warren, MHA, COC, CPC. Remember that if a procedure is also performed, the provider should document that the time calculations exclude separately reportable services. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
