Coding per MDM When Time is Documented


A provider completed an E/M in 25 min. The documentation supports Moderate MDM, does the service need to be down coded to a 99213 due to the documented time?


Under the new E/M guidelines, code assignment is per Time or MDM for codes 99202-99215.  Time does not need to be documented when coding based on MDM.  If time is documented but code selection is per MDM, confusion could easily arise. The provider should decide which method to use for final code selection and document to support.

However, clinicians shouldn’t be penalized for being efficient. If the patient is scheduled for a 15 minute appointment and moderate (or even high) MDM complexity is evidenced, allow the appropriate E/M code based on medical decision-making.