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Wiki Documentation of Counseling Time for E/M selection

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CJGORKA

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What is the best way in an EMR to document counseling time when time is used as a factor to select the E/M level?

Currently we have the provider document “Total face to face time __ minutes” and also document “Counseling was greater than 50% of face to face time”. Is that adequate or does the provider need to document the actual number of minutes spent counseling the patient as well as the face to face time?
 
CJGORKA said:
What is the best way in an EMR to document counseling time when time is used as a factor to select the E/M level?

Currently we have the provider document “Total face to face time __ minutes” and also document “Counseling was greater than 50% of face to face time”. Is that adequate or does the provider need to document the actual number of minutes spent counseling the patient as well as the face to face time?
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I was told that you must document what you counseled the patient on and the time spent doing it. Our docs state that I spent 80 minutes with the patient with over 45 minutes spent face to face discussing treatment options, this versus that, prognosis, coordinating care with....etc., etc.
Hope this helps...
 
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