Wiki Time documentation for E/M and separate procedure

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TWOlsen

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Hello! We have providers documenting their total time when a patient is seen in office, even when an additional procedure is performed. Is there a guideline somewhere that we can show to our providers to encourage them to separate out their time for the general visit from the procedure?
 
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It is in the Evaluation and Management Guidelines in CPT. It states, "Do not count time spent on the following: the performance of other services that are reported separately, travel, teaching that is general and not limited to discussion that is required for the management of a specific patient." (CPT, p.12) If the providers don't carve out the time spent in a separately billable procedure, you essentially can't code the E/M based on time.
 
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Yup - right in the CPT. Also in the AMA 2023 guidelines https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). It includes time regardless of the location of the physician or other qualified health care professional (eg, whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported service(s).

I advise my providers to edit their EHR system's templated existing time statement to include the phrase "excluding any separately billed tests or procedures." I let them know without that additional statement, I cannot count ANY of their time if there is another service provided.
This is my total recommendation to them:
Time wording suggestion: "I have personally spent ## minutes of time today on the encounter excluding any separately billed tests or procedures. This work included: reviewing prior records, obtaining and reviewing history, performing exam, counseling patient, ordering tests or procedures, documentation and care coordination."
There are of course other statements that would work, but it does need to state how many minutes were spent specifically on the E&M service.
 
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To the great guidance already offered I would add that if counting procedure time toward the E/M visit creates overpayments, your practice would need to return that money.
 
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