Is it required to document the amount of time spent on an encounter to support E/M coding?

Is it required to document the amount of time spent on an encounter to support E/M coding?

• A. True
• B. False
• C. Not specified
• D. Optional

Answer: (A)

When you code an E/M service based on time, the total amount of time spent with the patient on the date of the encounter must be documented to support the code level. The documentation should reflect the actual time spent and often includes a brief summary of the activities during that time (counseling, history review, exam, coordination of care). This time-based requirement exists because the code selection hinges on how long was devoted to the encounter. If you’re coding by medical decision making rather than time, you don’t have to document the exact duration to justify the code, though you still need to document the MDM elements. So, documenting the time is required when using time as the basis for E/M coding.

When you code an E/M service based on time, the total amount of time spent with the patient on the date of the encounter must be documented to support the code level. The documentation should reflect the actual time spent and often includes a brief summary of the activities during that time (counseling, history review, exam, coordination of care). This time-based requirement exists because the code selection hinges on how long was devoted to the encounter. If you’re coding by medical decision making rather than time, you don’t have to document the exact duration to justify the code, though you still need to document the MDM elements. So, documenting the time is required when using time as the basis for E/M coding.