TIME: If ALL responses regarding time are "Yes," billing may be based on time.
*If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, or risk education.
Does documentation reveal total face-to-face time? ☐ Yes ☐ No
Does documentation discuss the content of counseling or coordination of care? ☐ Yes ☐ No
Does documentation reveal that more than 50% of the time was spent on counseling or coordination of care? ☐ Yes ☐ No