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September 2, 2025

Clinical Staff Time

Question: I believe that I know the answer to this question but am hoping you know the source, as I can’t find it—if a nurse helps with ROS, medication reconciliation, etc., would their time (if documented) be able to be included in the time for the visit? Answer: No. The answer to this question is […]

When to Use Time to Select an E/M Service

Selecting a code for an E/M service can be done based on time or MDM (except ED visits which only use MDM) Time includes all time spent by the billing practitioner on the date of service, not just face-to-face time, and counseling does not need to dominate the visit, as it did in the 1995/1997 […]

E/M Services – History and Exam

History and exam for E/M services “E/M Codes that have levels of services include a medically appropriate history and/or physical examination when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified healthcare professional reporting the service. The care team may collect information and the […]

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