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metzger130

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I was wondering if anyone knows how you are supposed to document time when it comes to E/M. I know some physicians will want to do time instead of MDM. Do you have to say "I spent hh:mm to hh:mm reviewing reports. I spent hh:mm to hr:mm with the patient in the room, etc, etc. Or can you just say I spent # number of minutes with the patient total? I haven't seen any documentation stating how you are supposed to document time and didn't know if there was a standard that they are looking for.

Thank you!
Rob
 
metzger130 said:
I was wondering if anyone knows how you are supposed to document time when it comes to E/M. I know some physicians will want to do time instead of MDM. Do you have to say "I spent hh:mm to hh:mm reviewing reports. I spent hh:mm to hr:mm with the patient in the room, etc, etc. Or can you just say I spent # number of minutes with the patient total? I haven't seen any documentation stating how you are supposed to document time and didn't know if there was a standard that they are looking for.

Thank you!
Rob
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I'm wondering the same thing. I have providers wanting to know if there's a good "cheat sheet" available.
 
There is another thread here with this exact question. They don't have to delineate what the time for each portion is, or all they would be doing is documenting time. The new guidelines are supposed to reduce paperwork, not increase it.
 
I apologize if I duplicated a question, I did not see this question as I was scrolling through the questions.
 
what if a physician notes "spent more than 30 minutes but less than 39 minutes"? does this have to be exact?
 
It has to be Total time not an approximation or right about and you can based the time looking at the thresholds for the levels.
The documentation should be what took place /or the activities within that time that you are claiming for. It doesn't have to be
itemized. A brief but descriptive documentation with total time is what I have been hearing from multiple Webinars.
 
1) No itemization required
2) Simple statement of something like, "30 minutes of Physician face to face and non face to face time required for exam"

Tom Cheezum, OD, CPC, COPC
 
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