The physician documented an evaluation and management (E/M) service with key components of problem-focused history and examination and moderate-complexity medical decision-making. These key components support reporting of Current Procedural Terminology (CPT®) code 99212. However, the physician documented 20 minutes spent in counseling the patient and caregivers. Important to the consideration of whether the E/M service may be documented based on the time spent counseling is whether the documentation supports that more than 50% of the time of the physician’s face-to-face E/M service was spent in counseling and/or coordination of care. In this case, 3 elements of documentation are provided. The total encounter lasted 65 minutes (face-to-face time), with 30 minutes spent reviewing the data from the glucose monitor. That leaves 35 minutes dedicated to the E/M service, with 20 minutes (>50%) documented as counseling time. Per CPT instruction for time-based reporting, 20 minutes of time with...

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