Documentation Templates

Total time spent on the date of this encounter was *** minutes, including review of records prior to the visit, history and examination, review of imaging and laboratory results, counseling and answering the patient's questions, ordering of tests and medications, and coordination of care.

Note: enter a specific number of minutes; a range cannot be reported.

A significant, separately identifiable evaluation and management service was performed on the same day as the procedure, beyond the usual pre- and post-procedure work. The following problem(s) were separately evaluated: ***. Assessment and plan for the separate problem(s): ***.

Problem(s) addressed today: *** (state the complexity, for example acute complicated illness or injury, chronic illness with exacerbation, or a new problem with uncertain prognosis). Data reviewed or independently interpreted: *** (tests reviewed, external records reviewed, or a test performed by another provider that I personally interpreted). Risk of the management plan: *** (for example prescription drug management, a decision regarding minor or major surgery, or drug therapy requiring intensive monitoring). At least two of these three elements were addressed at the level supporting today's visit.

Note: Level 4 needs two of three elements at the moderate level; level 5 needs two of three at the high level. Total time on the date of service also qualifies on its own. State the specific problem, data, and risk rather than the words moderate or high.

Tobacco use was addressed. *** minutes were spent counseling the patient on cessation, including discussion of *** (risks, pharmacotherapy options, quit strategies).

Note: 3 to 10 minutes supports 99406; greater than 10 minutes supports 99407. State the time.

I personally and independently interpreted the *** (study), originally ordered by *** on *** (date). My interpretation: ***.

Note: independent-interpretation credit generally applies to a test ordered by another provider, not one you ordered and are simply reviewing.

This visit is part of my ongoing, longitudinal care of this patient as the continuing focal point for their *** condition(s).

Note: not reported when a same-day procedure with Modifier 25 is billed, except with a qualifying preventive service or wellness visit.

Total time on the date of service was *** minutes, exceeding the maximum time for the highest-level visit by at least *** minutes. Time was spent on ***.

Annual Wellness Visit components completed: ***. Separately, the patient raised the following problem(s) requiring evaluation and management: ***. Assessment and plan: ***. A significant, separately identifiable E/M service was provided in addition to the wellness visit.