Selection of Level of
E/M Service Based on Duration of Coordination of Care and/or Counseling
Time is the key factor in selecting the level of service when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face
physician/patient encounter or floor time (in the case of inpatient services). In
general, thephysician must complete at least two out of three criteria applicable to the
type/level of service provided to bill an E/M code. However, the physician may
document time spent with the patient in conjunction with the medical
decision-making involved and a description of the coordination of care or
counseling provided. Documentation must be in sufficient detail to support the
claim.
Example:
A cancer patient has had all preliminary studies completed and a medical decision is made to implement chemotherapy. At an office visit, the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.
