True, there needs to be at least a couple of sentences detailing what was the reason for counseling/coordination of care.
FROM CMS FAQ on TIME BASED CODING
Q1. When using time as the determining factor for inpatient evaluation and management (E/M) services, does greater than 50% of the time have to be spent in counseling/coordinating care (C/C), or is documenting total time spent on the unit/floor sufficient documentation?
A1. A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care and the nature of the counseling/coordination of care must be in the medical record.
If the medical record does not reflect the required documentation, then use the three key elements of history, exam, and medical decision-making to choose the procedure code.
In the office setting, document the total face-to-face time with the patient. In the inpatient setting, document the total face-to-face time with the patient or on the patient's floor or unit. The face-to-face time refers to time spent with the physician only. Time spent with other staff is not considered in selecting the appropriate level of service.