Does documentation of more than 50% of time spent counseling or coordinating care suffice for time documentation, and therefore E/M code level selection? Many will answer: YES
Let’s take a peek at an often forgotten CMS rule
“In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim. Full manual description is found in IOM, ch.18.104.22.168C.
Don’t forget MDM
CMS is explaining that the MDM must be considered in combination with the time spent. Various resources including the CMS and AMA, have been reviewed and state that the provider must document the total time and describe the counseling/coordination of care consisted of to support the medical necessity. Although, this statement is different as it advises that the time and the MDM must support the same level of service. After reading this statement you may be concerned that you have been scoring time based documentation incorrectly.