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Clarify for documentation of a follow-up visit; is it appropriate to say it is unchanged from the initial consult?

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Clarify for documentation of a follow-up visit; is it appropriate to say it is unchanged from the initial consult?

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If it is unchanged, it is appropriate to document that it has not changed. Q: As a pulmonologist and sleep specialist, I spend a lot of time discussing management, CT scan results, sleep studies, and management of sleep disorders. Most of these are time- based. How do we do that best? A: You can bill for time, if the following criteria are met: You actually document the time, ie, 45 minutes, 3:00-3:45 pm. You describe in your note the content of counseling or coordination of care. More than half of the total time was counseling or coordination of care. Average times are noted in the AMA CPT book with each of the evaluation and management services and in the ACCP coding book in the tables on pages 64-68, 111-113 for critical care and page 283 for the teaching physician rule.

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