Wiki E/M Time Help Needed

[AngelaRucker]

Hello,

I am billing for an OP Established E/M visit. The provider states "Total time for visit: 28 minutes face-to-face with the patient." Would you bill 99213 or go up to 99214 (assuming) extra time was taken to document the visit in the EMR? Is there a set allowance of time spent for documenting the CC, HPI, ROS, Exam and PFSH as well as all other documentation into the EMR?

 

[csperoni]

While the 2021 outpatient guidelines allow to count all time provider spent the day of the visit, you cannot assume the other time if not documented. You may only count 28 minutes.
This is a good opportunity to educate your provider about the new guidelines.