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Wiki What E&M if any?

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Tonyj

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I'm having a moment of brain freeze.
Pt comes in with wife for a "quick discussion" on how to proceed with treatment. Physician documents fully everything discussed with the pt and wife. Clinical trials available, loss of time, adverse effects and documents a total 25 minutes spent.

Can I code this as a level 4?
No HPI, No exam, No MDM only content of discussion with the patient was documented.
 
what E/M, if any?

You can certainly bill a level IV, based on time spent, if the provider documents the total time, the counseling time (must be greater than 50% of the total time), and describes the counseling/coordination of care given.
 
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