To code office/outpatient visits based on time, add the minutes a physician or qualified healthcare professional spends on a variety of activities, including the time it takes them to update the patient’s medical record. To accurately document and code office visits with time, it’s important to understand the activities that count toward time. Because it is unlikely that every visit will include every activity, providers may overlook activities that they rarely perform.
The following illustration will help providers not miss out on countable activities.
A “discussion of management or test interpretation” can earn a moderate or high score under the data review element of an E/M office visit. But before you give the billing practitioner credit for a discussion, make sure the documentation shows that it met the definition of a discussion.
Use the following illustrated guide on discussions to train staff.
Health information management, Hospital inpatient, Physician queries
The following sample policy regarding query escalation and resolution addresses the specific timing expectations for query responses, how coders should communicate with CDI staff and physician advisors, and what circumstances might warrant raising an unanswered query to the attention of a CDI or HIM manager, physician advisor, or higher-level administrator.
Coders can use this reference sheet to identify common reasons to query for acute myocardial infarctions. It also provides scenarios for each reason. This information was excerpted from information provided by Rhoda Chism, MHL, RN, CCDS, CCS, CPHQ, and Debra Rush, RN, CCDS, during the HCPro webinar, “What the Bleep is Beeping? Getting to the Heart of the Matter: Cardiac Critical Care Review.”
Coders can use this E/M reference chart to identify the amount of time necessary to report E/M services. It also details which tasks that healthcare providers complete would qualify as time spent on E/M services. This information and infographic were excerpted from2024 Pain Management Coding Answers.
