ICD10monitor February 5, 2024
Erica E. Remer, MD, CCDS

I am currently performing a fraud assessment, and since I can’t go back and educate the provider in question, I am going to share my insights with you. Since Jan. 1, 2023, practically speaking, all evaluation and management (E&M) service coding is based on medical decision-making or time. And some providers are not documenting time appropriately.

  • It’s no longer only face-to-face (F2F) time or time spent on the floor or unit that counts. It is the total time devoted to the patient, which includes some component of F2F time on the day of the encounter.
    Consider the following:
    • The face-to-face time may be delivered by another qualified healthcare professional, as opposed to the ultimately responsible billing individual, if...

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Topics: HIM (Health Inf Mgmt), Physician, Provider, RCM (Revenue Cycle Mgmt), Technology
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