Key E/M components missing? Consider counseling if doctor spends more than 50% of time counseling patient

Why This Topic Matters

Accurate time documentation can affect whether an encounter is captured at the appropriate E/M level and whether the record supports reimbursement during audits. The article highlights common documentation gaps and why they matter in everyday GI practice.

Article Sections

1. Counseling and/or coordination of care in a GI office visit

   Discusses a gastroenterology follow-up scenario and how counseling time can factor into evaluation and management reporting. The section focuses on documentation considerations in a time-based visit context.

2. Why documentation of time matters

   Explains common recordkeeping issues and the importance of capturing total face-to-face time and the general subject of the discussion. It also addresses how practices may improve awareness of time spent during visits.

3. Four keys to report counseling and/or coordination of care

   Summarizes broad requirements for using counseling or coordination of care in E/M reporting. The section presents general points about time, face-to-face contact, and documentation.