hi smillar - they need to at least give total time spent with patient, and state that at least 50% of it was spent in couseling/coordinating and a bit of description of their services.
If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.
3 questions to ask are:
1) Does documentation reveal total time? (face-to-face in outpatient setting; unit/floor in inpatient setting)
2) Does documentation describe the content of counseling or coordinating care?
3) Does documentation reveal that more than half of the time was counseling or coordinating care?
If all answers are “yes”, you can select a level based on time.
*there you have my three pennies worth*
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