Time Threshold E/M Billing And CPT ® Coding Reference Tables.

Evaluation and management CPT ® coding isa set of a highly complex  rules that must be mastered for physicians to accurately submit charges for services provided.  Make sure to review the AMA CPT 2016 Standard Edition as the definitive authority on codes.   I am not a certified coding expert, but I have studied this stuff for years and have a great grasp on the E/M process.  Despite that, the rules are so complex that after a decade of hospitalist work,  I still carry a bedside E/M reference card (see at bottom of post) with me at all times to make sure I am submitting the correct E/M charge on every patient encounter, every time. Is there an easier way to stay in compliance with archaic E/M rules for hospital and clinic encounters?  Yesthere is, but only under limited circumstances.   It is possible to submit an E/M charge that ignores all the complex rules of evaluation and management and is based on time instead.  The rules for billing based on time are much simpler.  Just three requirements are necessary when submitting E/M charges based on time spent.  The requirements are:Documentation of total time (face-to-face/floor time)Documentation describes the content of the counseling and or coordination of careDocumentation supports greater than 50% of the total time spent involved counseling and or coordination of care.If these three rules are met on your E/M evaluations, then physicians can bill based on ...
Source: The Happy Hospitalist - Category: Internal Medicine Authors: Source Type: blogs