Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 15, 2021

Question:
Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit?

Answer:
According to advice from the AMA (3/24/21 webinar), you should only document one or the other to prevent potential audit confusion and risk. Document time if billing by time OR medical decision making if billing by medical decision making.

*This response is based on the best information available as of 4/15/21.

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