leastratton1001
Contributor
Can anyone clarify is there are any regulations as far as time when it comes to documentation. For example- the E&M guidelines for time indicate that it is "total time on the day of encounter", but we are often seeing clinicians finish up their documentation in the EMR as late as the next day or day after. Are we allowed to utilize that time or must it only be the time spent on the actual day of encounter? I am hearing conflicting answers and cannot find anything solid except for "total time on the day of encounter" which leads me to believe if they do not finish it on the day of encounter we cannot utilize it for time.