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99291 E/M INSIGHT
 

 
Notice that there are no specific documentation requirements for the key components of E/M documentation for critical care notes. The documentation of the history, physical exam and medical decision-making is left up to the discretion of the examiner.

Technically, all that is required is documention in the chart of the time spent of critical care services (in the clinical example, 37 minutes was clearly stated in the chart).  However, in order to demonstrate medical necessity, it is always a good idea to outline the nature of the clinical problems beng addressed. 
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