FAQ #12
       
How do I code for an E/M service based on time?

Answer: Some types of encounters have different times assigned to the various levels of care (e.g., office visits). Other encounters do not have allotted times (e.g., ER visits). For those encounters with assigned times, you always have the option of coding based solely on time as opposed to coding based on the documentation of the key components of history, exam and medical decision-making.

If you choose to code based solely on time, then you MUST spend the entire allotted tome face-to-face with the patient. You must then document the time spent as well as the issues you discussed. In addition you must state that over half of the time spent was devoted to "counseling and/or coordination of care." If you do this, there are no specific requiremetns for the documentation of the history, exam and MDM because you are basing the level of care solely on the amount of time spent with the patient.