Dont' get stuck on WHERE the physician documents, as long as the documentation fully meets the criterion. I've seen progress notes that are just one long paragraph ... chief complaint, HPI, ROS, history, exam, MDM, assessment, plan, etc all lumped into one big paragraph. Makes no difference. It's your job as a coder to decipher all the documentation and translate it into the appropriate code.

The key is whether the physician has documented:
1) total time spent Face-to-face with patient
2) Time spent in counseling/coordination of care (must be more than 50% of total time
3) Nature of counseling/coordination of care

If what is documented meets the above three elements, you can assign an E/M code based on time spent in counseling/coordination of care.

Hope that helps.