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Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

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February 5, 2023

Clinical staff time

Question: I believe that I know the answer to this question but am hoping you know the source, as I can’t find it — if a nurse helps with ROS, medication reconciliation, etc., would their time (if documented) be able to be included in the time for the visit?

Answer: No. The answer to this question is in the CPT® book, in the E/M section, page 8. In a discussion of total time for office visits it says

“For coding purposes, time for the services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified healthcare professional and does not include time in activities normally performed by clinical staff).

Later on that page, it says that the time of the physician/other qualified health care professional can include reviewing separately obtained history. But the time of the clinical staff member who obtains that history may not be included.

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Last revised August 22, 2022 - Betsy Nicoletti
Tags: E/M rule changes

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

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2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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