kculter
New
If a provider documents the total time for an office visit in their note, but the medical decision making of the visit would justify a higher code level than the total time statement, can the CODER choose to bill the e/m code based on MDM, even if the total time statement is still present in the provider's documentation?
There is a difference of opinion in my office about this. I've always viewed it as the provider's choice between using MDM or time, not the coder reviewing the documentation. If the time statement is present that is what I code from.
Here is an article a coworker provided to try to support the coder being able to choose MDM over documented time:
So far I cannot find any official sources (AMA, etc.) to confirm or deny this either way. If anyone has links to sources they can include that would be very appreciated.
Thank you!
There is a difference of opinion in my office about this. I've always viewed it as the provider's choice between using MDM or time, not the coder reviewing the documentation. If the time statement is present that is what I code from.
Here is an article a coworker provided to try to support the coder being able to choose MDM over documented time:
E/M Level when time and MDM are documented
Your coding questions answered.
www.physicianspractice.com
So far I cannot find any official sources (AMA, etc.) to confirm or deny this either way. If anyone has links to sources they can include that would be very appreciated.
Thank you!