Use care when using “time” to support an E/M service: The Documentation Guidelines are clear that there are History, Exam and MDM elements necessary to support each level of service.

However: “…when counseling and/or coordination of care dominates (more than 50%) of the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or hospital) then time shall be considered the key or controlling factor to qualify for a particular level of service.”

Not all situations will allow for this exception, and certain situations need to be clarified for appropriateness. Can you pass an audit if you use time?

Terry will also discuss your documentation evidence that a counseling and/or discussion was had with the patient.

Plus, a bonus topic: Are your patients having you dropped from your commercial contracts? Listen in to find out.

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