Coordination of care is any activity necessary to arrange for health care or collaborate with others, such as ordering tests, discussing test results or treatment recommendations, hospital admission, and/or referral to other providers. In the context of billing an evaluation and management (E/M) service based on time, coordination of care must take place either face-to-face with the patient for E/M services in outpatient settings or on the unit/floor for inpatient or observation services. Here is an example of coordination of care in the office setting.

Dr First is the general pediatrician for a patient presenting with symptoms of an illness that requires testing, which is completed during the visit. Dr First interprets the test results in light of the patient presentation and, after discussing the findings with the patient and caregivers, decides to consult a specialist at the local hospital. With the patient present, Dr First discusses the patient presentation...

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