Some Evaluation and Management codes, and some other codes are defined by the amount of time of the service.
When a CPT® code is defined by time, the clinician must document time in the medical record.
Examples of this are:
- some psychiatry codes
- certain physical therapy modalities
- critical care services
- the second level discharge visit
- prolonged services
When you look at the definition of a CPT® code, if time is listed, document time in the medical record.
You can also use time to select Evaluation and Management codes if typical time is listed for that code in the CPT® book and the visit is predominately counseling and coordination of care. Document the total time of the visit, the fact that more than 50% of the visit was counseling and the nature of the counseling.
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