Time vs. MDM

kkirkland

Networker
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Location
Royal Oak, Michigan
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For E/M codes prior to the changes in 2021, does anyone know of any sources that definitively state that you may (or may not) choose between time or MDM when time is documented? Do you have to code based on time when it is given or can you go with the elements if that more accurately describes the complexity of the visit?
 

SharonCollachi

True Blue
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793
Location
Clovis, CA
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Documentation of time is not an acceptable method of choosing a code. ONLY if counseling and/or coordination of care is more than 50% of the time spent is time a reason for choosing a code.

CPT book will tell you.
 

thomas7331

True Blue
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CPT definitively does state this in the E&M section guidelines under 'instructions for selecting a level of E/M service':
When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.
 
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