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LBMC has the experience and expertise to provide clients with cost-effective and complete coding and compliance services.

Jenny Harvey, RHIT, CPHQ, CPC, CPMA, AHIMA Approved ICD-10-CM/PCS Trainer
LBMC咨询服务经理
医疗咨询

的 美国医学协会 (AMA) released new guidelines on January 1, 2023. CPT® published new rules for using time to select a level of Evaluation and Management (E/M) service. 现在, these rules apply equally to services performed in the office, 医院, 或者护理机构. 这看起来很简单，对吧? Review the time documented in the medical record and assign the corresponding E/M code.

Time-based coding for outpatient E/M services can be challenging, 但如果有适当的文件, 这很容易管理. Medical necessity requirements are still non-negotiable.

Supporting documentation must be present to substantiate the medical necessity for the E/M service. 的se documents should provide detailed and specific information to justify the time spent during the encounter. Total time includes both in-person and remote activities performed by the provider on the day of the encounter.

计算为E/M时间的活动

• 准备见病人(e).g.(检查测试)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• 订购药物、检查或程序
• Referring and communicating with other health care professionals (when not reported separately)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver
• Care coordination (not reported separately)

不计算花在以下方面的时间:

• 的 patient was seen on a calendar day other than the day they spent time
• 其他单独报告的服务, 比如程序, AWV, 慢性护理管理, 以及过渡性护理管理
• 旅行
• Clinical staff time (activities performed by medical assistants, nurses)
• Time spent on general teaching that is not limited to discussion required for the management of a specific patient

陷阱之前

• Don’t double count total time spent on the E/M service if it’s already been separately reported. Time must be exclusive to the E/M service only.
• Extra reported service time must be subtracted from total E/M time and be documented accordingly.

还记得, an E/M time attestation carries the same penalties for false reporting as anything else in the claim. Use it judiciously and record it accurately.

Accurate documentation and following medical necessities are important in healthcare services. This is especially true under the new AMA and CPT® guidelines for time-based coding. 仔细考虑活动, 避免重复计算等陷阱, and accurate recording are essential for compliance. For expert guidance in navigating these guidelines, LBMC’s 医疗咨询 team is ready to assist you.