Documentation Based on Time
A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care and the nature of the counseling/coordination of care must be in the medical record.
“I spent 15minutes (total time 25 minutes) discussing diagnosis of hypertension and treatment options. Patient’s questions relating to diagnostic tests results and new medications were answered. Patient was given dietary fact sheet and information was discussed. The importance of compliance and follow-up care was stressed to patient. ”