Even though a patient spends a long time with their physician, that doesn’t necessarily translate into high medical decision-making. The patient may require lots of attention—maybe they diagnosed themselves on the internet and the physician is reorienting their thinking and there are several treatment options to discuss—but the medical decision-making could be low. The dance of time versus medical decision-making has big implications now that physicians base their evaluation and management (E/M) levels of service on the documentation of either one without factoring in the history and exam. That applies to office and other outpatient visits now, and will reach hospital visits starting Jan. 1.

Choices about coding based on time versus medical decision-making can get complicated, said Raemarie Jimenez, chief product officer for the AAPC, on Aug. 20 at the Collaborative Compliance Conference sponsored by AAPC and the American Health Law Association. “A physician can code the service based on time or medical decision-making and make that decision patient by patient,” she said. Some physicians may always choose medical decision-making. Other physicians will code based on time because “medical decision-making is too hard to wrap their heads around and they can track their time and feel good about it,” Jimenez said. “There’s nothing wrong with that.” The question is whether facilities take the higher code when coders recognize the service would generate more reimbursement if it’s coded based on time versus medical decision-making or vice versa. Either way, they have to “honor” that it’s the physician’s provider number and “what their comfort level is,” Jimenez said. She suggested facilities have a policy to guide these decisions.