Answer
When 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 outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or controlling factor to qualify for a level of E/M services. If the level of service is reported based on counseling and/or coordination of care, you should document the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care.

Resources

  • CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 12 (PDF, 1.1 MB), Section 30.6.1.C
  • CMS MLN Evaluation and Management Services Guide

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