What must be documented when an E/M service is based on time?

When an Evaluation and Management (E/M) service is primarily determined by time, it is crucial to document not just the total time spent but also the specific details related to the counseling and coordination of care involved in the visit.

Documenting the percentage of time spent on counseling is essential as it indicates how much of the overall service was dedicated to patient engagement in discussions about their care, which is significant in determining the complexity and value of the visit. Furthermore, detailing the content of the conversations is important because it provides context to the counseling provided, showing the decision-making process, any relevant issues discussed, and how that aligns with the patient’s treatment plan.

This thorough documentation supports the medical necessity and appropriateness of the visit, substantiating billing for the level of service rendered based on time spent appropriately. Therefore, both the percentage of time spent on counseling and the details of conversation content need to be documented to comply with the requirements for E/M coding based on time.