Use Time Component When Coding Counseling, Coordination of Care Visits

It is vital for providers to implement best practices in documenting time-based E/M services. Below are three important components to keep in mind to include in the patient’s medical record when using time as the key factor for a level of service:

1. Document the total time of the visit;
2. Include the total time spent in counseling and/or coordinating care; and
3. Provide a summary of the discussion.

For questions or additional information on coding guidelines and documentation for your organization, contact the ACR coding and auditing professionals at [email protected].

Reference

1. Centers for Medicare & Medicaid Services. CMS Manual System. Pub 100-04 Medicare Claims Processing. Transmittal 1875. 2009 Dec 14.