Wiki Evaluation and Management services


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Im having trouble understanding E/M services.

Can someone explain how to code an e/m if the time the physician spent with the patient doesn't match the history and/or medical decision making?

Do i code what can be proven with the history noted? or a higher level of E/M due to the time the physician spent with the pt?

Any help is greatly appreciated!!!
The basic rule is that the amount of time spent with the patient can only be used to determine the E/M level if more than 50% of that time was spent counseling and/or coordinating care. In order to use the time element, the provider must document 3 things: 1) the total time of the encounter, which must be face-to-face time if seen in the office or floor time spent on that patient if seen in the hospital; 2) that more than half of that time was spent counseling/coordinating care, either by stating the amount of time spent in counseling/coordinating care or with a statement that shows that more than half of the time was spent doing this; and 3) a description of the content of the counseling/coordination of care. If these are documented, then the E/M level can be chosen either by the key elements of history, exam and MDM, or by time, whichever is higher.
Time spent with the patient is not a good indicator of an E&M. I use the 95 or 97 E&M determination to see what the provider did, rather than looking at time spent.