If I noticed a provider is using TIME to determine their level of service because they document the time but I also noticed that the documentation supports a lower level based on MDM, since we are not doing an audit, is it safe to just leave the level of service based on what the provider chose and as long as the documentation supports the TIME guidelines?
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Wiki MDM vs Time
- Thread starter KoBee
- Start date
bgrasson
Networker
Yes- the new guidelines state you can use either or as long as the time is documented.
Thank you for the response, I just get worried I maybe doing something incorrect if I leave the level of service based on his TIME that he is documenting even though Im checking he meets guidelines. Sometimes some providers want to use a higher level E/M by using TIME when MDM may support a lower E/M and that can flag an audit, correct?
SharonCollachi
Guest
No, not correct as of 1/1/2021.
Indeed. I believe that you have the ability to choose whichever one gives the higher level, if I'm not mistaken.
That's the Million dollar question. Is that in fact the rule. I can't seem to find that spelled out anywhere....
Orthocoderpgu
True Blue
Page two first paragraph "Beginning with CPT 2021....time alone may be used to select the appropriate code level for the office or other outpatient E/M service".