medicalauditor
Networker
Hi guys,
I have a question about selecting an E/M level based on time when counseling and/or coordination of care dominates (greater than 50% of face-to-face time) the encounter. I know and understand the documentation requirements for this, however, my question is - Does choosing an E/M code based on time mean that the encounter does not need to have the 3 key elements of history, exam and MDM? My understanding is that every E/M visit still needs to have history, exam and MDM to qualify as an E/M service, but that the LEVEL of the E/M code can be based on the counseling time. Am I right? If so, can anyone guide me to a CMS resource or some other credible resource that states this? Thanks so much.
I have a question about selecting an E/M level based on time when counseling and/or coordination of care dominates (greater than 50% of face-to-face time) the encounter. I know and understand the documentation requirements for this, however, my question is - Does choosing an E/M code based on time mean that the encounter does not need to have the 3 key elements of history, exam and MDM? My understanding is that every E/M visit still needs to have history, exam and MDM to qualify as an E/M service, but that the LEVEL of the E/M code can be based on the counseling time. Am I right? If so, can anyone guide me to a CMS resource or some other credible resource that states this? Thanks so much.