Wiki Can a coder choose MDM over documented total time?

[kculter]

If a provider documents the total time for an office visit in their note, but the medical decision making of the visit would justify a higher code level than the total time statement, can the CODER choose to bill the e/m code based on MDM, even if the total time statement is still present in the provider's documentation?

There is a difference of opinion in my office about this. I've always viewed it as the provider's choice between using MDM or time, not the coder reviewing the documentation. If the time statement is present that is what I code from.
Here is an article a coworker provided to try to support the coder being able to choose MDM over documented time:

E/M Level when time and MDM are documented

Your coding questions answered.

www.physicianspractice.com

So far I cannot find any official sources (AMA, etc.) to confirm or deny this either way. If anyone has links to sources they can include that would be very appreciated.

Thank you!

 

[jkyles]

Hi there,

The AMA has said that E/M visits can be coded based on time or MDM. When one method would produce a higher level code than the other it is fine to select the higher code. For example, here is a quote from Novitas https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056

Effective for dates of service (DOS) on and after January 1, 2023, practitioners have the choice to document most E/M visits via medical decision making (MDM) or time, except emergency department visits and cognitive impairment assessments, which are not timed services.

Because of this guideline it is best practice, but not mandatory, for the provider to include time documentation for their E/M visits. That way the coder can decide whether to code based on time or MDM. In addition, documenting total time gives providers the chance to report prolonged service codes when appropriate. (The provider should make sure they're counting all eligible time on the date of the encounter.)

Based on your question I can't tell if the provider has expressed a preference. Even though it is appropriate to code the highest appropriate level I think it would be a good idea for your practice to work out an internal policy for this situation.

 

[sls314]

If a provider documents the total time for an office visit in their note, but the medical decision making of the visit would justify a higher code level than the total time statement, can the CODER choose to bill the e/m code based on MDM, even if the total time statement is still present in the provider's documentation?

There is a difference of opinion in my office about this. I've always viewed it as the provider's choice between using MDM or time, not the coder reviewing the documentation. If the time statement is present that is what I code from.
Here is an article a coworker provided to try to support the coder being able to choose MDM over documented time:

E/M Level when time and MDM are documented

Your coding questions answered.

www.physicianspractice.com

So far I cannot find any official sources (AMA, etc.) to confirm or deny this either way. If anyone has links to sources they can include that would be very appreciated.

Thank you!

The coder can choose between MDM or time, whichever is more advantageous. Of course, the level has to be supported by the documentation.

The provider doesn't have to be the one to select the E/M level. Frankly, I prefer it when they leave it up to me. I review all of the E/M levels for my physicians and make corrections as needed before the bill goes out the door.

Unless your practice has some internal policy where the physician insists that their E/M levels never be altered, there's no reason a coder can't make the final leveling decision based on E/M or time.

 

[luvbuix]

they should put both on their note & choose the level based on whichever component is the highest. the new guidelines help them/and you optimize their coding. we have cancer pts that get 10-15 min office visits- if they are getting chemo obviously the MDM would be what you would code from. we also have anemia pts that may be stable & are not currently maintained by drugs. they may have an office visit that takes 40 mins- obviously we'd use time for that one.