Code selection is always based on the documentation of the service provided. This article includes tips to help pediatricians document office evaluation and management (E/M) services (99202–99205, 99212–99215) and support code selection for the problems addressed, data reviewed and analyzed, risk of further management or treatment, and time spent on the date of the encounter.

Although documentation of office E/M services no longer requires a specified number of history and examination elements, documentation should reflect each of the activities that drove the MDM at each visit. Documentation of total time for each patient’s visit also leaves open the option of reporting based on time.

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