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Documentation for Time Based Codes: Documentation for Time Based Codes When counseling and/or coordination of care makes up more than 50% of the time the physician spends with the patient in the office, then the level of care can be selected solely on the basis of the time spent. Level 1 Level 2 Level 3 Level 4 Level 5 New patient visit 10 min 20 min 30 min 45 min 60 min Consultation 15 min 30 min 40 min 60 min 80 min Established patient visit 5 min 10 min 15 min 25 min 40 min Visit code selection is based on the total face-to-face encounter time between physician and patient, not just the counseling time. Only the doctor’s FACE TO FACE PATIENT time counts. Time spent by other staff cannot be included. Time spent coordinating the patient’s care after the patient has left the office cannot be included. The medical record should document: - Total time spent by the physician with the patient Time spent counseling A description of the coordination of care or counseling provided Established Patient Example: “I spent 15minutes (total time 25 minutes) discussing diagnosis of hypertension, prognosis and treatment alternatives. Answered patient’s many questions concerning results of diagnostic tests and new medications. Discussed and gave pt. information on diet. Stressed importance of compliance and follow-up with above. ” Above example would be a 99214-Established patient level 4. New Patient Example: Spent 30 minutes of 35-minute visit discussing with new OB transfer patient our practice style. Answered many questions related to care and followup provided by this practice. Gave patient information on pregnancy and delivery. Above example would be a 99203—New patient level 3. Counseling may include one or more of the following: - Diagnostic results, impressions and/or recommended diagnostic studies Prognosis Risks and benefits of management/treatment options Instructions for management and/or follow-up Importance of compliance with chosen management/treatment options Risk factor reduction Patient and family education