Wiki Time - E/M 2021

[KoBee]

Hello everyone -

Need some clarification, is " reviewing records " enough to use in a providers time statement how time was utilized.

I was thinking more in the lines the provider needed to specify if reviewing records was prior, during, or after seeing the patient and what records where reviewed. I'm seeing providers not documenting any of that.

This is an example:
About 80 min spent evaluating the patient, reviewing records, decision making and counseling.

 

[beulastella]

When you have the Total time you can consider the level based on the time. It is not required to do such an investigation and validate the timings split.

 

[lcolborn]

Hello everyone -

Need some clarification, is " reviewing records " enough to use in a providers time statement how time was utilized.

I was thinking more in the lines the provider needed to specify if reviewing records was prior, during, or after seeing the patient and what records where reviewed. I'm seeing providers not documenting any of that.

This is an example:
About 80 min spent evaluating the patient, reviewing records, decision making and counseling.

I would take out the word, " about " . This word seems to give you an approximation, all is needed is the total time , " 80 minutes " . Total time spent and the activities of the day, face to face or non face to face. Proper documentation is important to support the medial necessity and the total time spent .