Coding Notes: Time Alone Is Sufficient to Select a Counseling Level of Care

Why This Topic Matters

Accurate time documentation can affect E/M level selection and reduce ambiguity when counseling is central to the visit. The article helps readers identify when time-based coding is applicable and what types of encounter details should be documented to support coding choices.

Article Sections

1. Remember What’s Included

   This section outlines the general types of encounter time that may be considered when counseling and coordination of care are the main focus. It also distinguishes the time that can be counted from other work done around the encounter.

2. Document the Extent of the Counseling

   This section discusses documentation practices for recording counseling time and indicating when counseling dominates the encounter. It also emphasizes the importance of clear time documentation for selecting an E/M level.