An established patient office visit is dominated by counseling, with 40 minutes of total time on the date of the encounter documented. How should E/M selection be approached?
Select an answer to reveal the explanation.
Short Explanation
When the clock—not the MDM puzzle—is how you level, 40 minutes of total face-and-non-face work on that date points to the matching established office code. Don’t invent critical care or a second ‘new patient’ out of thin air.
Full Explanation
Office/outpatient E/M may be selected by total time on the date of the encounter when time is used instead of MDM. Documented total time that meets a level’s threshold supports that established-patient code. Critical care and new-patient categories require their own criteria and do not replace time-based established office E/M solely because counseling dominated the visit.