Documenting Time in 2023
The burden of documenting time in 2023 just got lighter. This is good news. According to Revenue Cycle Intelligence, time-based billing reaps more rewards for complex patients with longer visits. MDM leveling nets higher returns for shorter encounters.
Having said that, capturing your total time and activities for the day requires more than just a dot phrase. Your documentation should include patient-specific encounter information.
Best practice, just keep it simple. Document a clinically relevant history and exam, your assessment and plan. Include your total time, and describe how that time was spent caring for the patient that day. In addition, if you have performed services that are separately reportable, the recommendation is that you state that time was not included in your total E/M time.
Do not use an unedited dot phrase that says the exact same thing from encounter to encounter. Or worse, patient to patient. Document patient-specific encounter information. This doesn’t need to be a novel. A short story will do, as long as you have written it well. Volume does not overcome a lack of specificity. For internal non-AAPC members, you can find their E/M FAQs here. The AAPC also published a new article on TIME you can view here.
Per the AMA, the following activities may be included in your total time (see below).
Activities that may be included in your total time:
■ preparing to see the patient (e.g. review of tests)
■ obtaining and/or reviewing separately obtained history
■ performing a medically appropriate examination and/or evaluation
■ counseling and educating the patient/family/caregiver
■ ordering medications, tests, or procedures
■ referring and communicating with other health care professionals (when not separately
reported)
■ documenting clinical information in the electronic or other health record
■ independently interpreting results (not separately reported) and communicating results to
the patient/family/caregiver
■ care coordination (not separately reported)
Activities that may not be included in your total time:
■ the performance of other services that are reported separately
■ travel
■ teaching that is general and not limited to discussion that is required for the management
of a specific patient
If you are sharing a visit with an Advance Care Practitioner in the facility setting, make sure you also meet those requirements (see below).
In summary, your documentation needs to demonstrate the total time you spent caring for your patient that day, and describes activities you performed during that time. Clinical staff time does not count towards your total time.
MSHBC has created a combined MDM/Time 2023 E/M Cheat Sheet you can get here.
If you would like additional information regarding E/M documentation, please feel free to contact me at Caroline.Wolbrecht@uth.tmc.edu.