Selecting the level of service for a new patient office visit requires every one of the 3 key components—history, physical examination, and medical decision-making—to be met. Time can be used as the key or controlling factor in the selection of an office or outpatient evaluation and management service when more than 50% of the physician face-to-face patient or family encounter is spent in counseling or coordination of care. Therefore, the performance of a physical examination is not required on a new patient if more than 50% of the total face-to-face physician-patient (or family) encounter is spent in counseling or coordination of care. Always document the total face-to-face time of the visit, the counseling time, and a summary of the issues discussed.

You do not currently have access to this content.