I’m wondering if you would assign the E/M Level based on the Counseling/Coordination of Care time if it is LOWER than what the documentation meets (within the Hx/Exam/MDM). The guidelines indicate that when the encounter is dominated by counseling/coordination of care than TIME should be the controlling factor in determining the level of service. Further, I think we all know how EHRs make it easier to get to higher levels. But I am seeking my peers’ expertise – what would you do? Assign the level based on the time even if it’s lower than the key components? Or maximize reimbursement?

Thanks in advance for your input! If you have any reference material that would be greatly appreciated, too.