Which factors must be documented when selecting an Evaluation and Management (E/M) level based on time?

When selecting an Evaluation and Management (E/M) level based on time, it is essential to document several specific factors to ensure compliance with coding guidelines and accuracy in billing. The total time spent is critical because it reflects the overall amount of time dedicated to the patient's care, which is a key determinant in coding the E/M level. Additionally, documenting the percentage of time spent with the patient provides clarity on how much of that total time was directly related to patient interaction, which is crucial for justifying the chosen level of service. Moreover, recording what service was provided during that time is necessary to outline the nature of the services rendered and how they relate to the patient's condition and treatment plan.

Documenting all these factors together allows for a comprehensive picture of the visit, ensuring that the chosen E/M level accurately reflects the complexity and time involved in the patient’s care. This thorough documentation helps protect against audits and supports the medical necessity of the services billed. Thus, including all of these elements strengthens the case for the selected E/M code, making it essential to document total time, percentage of time with the patient, and specifics of the services provided.