The other thing to remember is if you are looking at a patient who has Medicare (or insurances who follow Medicare's E&M rules) the chart must have 2 things to have compliant documentation when time is used as the rationale for code selection: #1) total time of visit #2) number of minutes of counseling and coordination of care or a % of the total time.
MCM Chapter 1 Sec 30.6.1.C
The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.
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