Wiki Evaluation and Management services

[krnmndz]

Hello,

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!!!

 

[thomas7331]

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.

 

[rantonelli]

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.