Evaluation and Management (E/M) Outpatient Visit
When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family, that time can be considered the controlling factor to qualify for a particular level of E/M services. To use time as the reporting factor for a level of E/M service. The documentation should support the medical necessity of treatment and diagnosis. The following must also be documented:
- The total time of the encounter
- The counseling and/or coordination of care time
- The description of the counseling and/or coordination of care
- May be used when services are provided via telehealth