In the case where counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of Evaluation and Management (E/M) services.
| Documentation Guidelines |
| DG: |
The duration of counseling or coordination of care that is provided face-to-face or on the floor (inpatient setting) may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling. |
| DG: |
The medical record must be documented in sufficient detail to justify the selection of the specific CPT code if time is the basis for selection of the code. |