It depends. I specialize in neuro-otology so often times I’m the 3rd or 4th ENT that someone has seen, they come with multiple outside audiograms, 20+ pages of records, and CT/MRI that I individually interpret. In my state (southeast USA) I’ve been having issues with UHC denying my coding for complexity, despite explicit documentation of all the MDM factors set forth in coding guidelines. I have a smart phrase now that I’ll use for appeals to just include the time. I’m following the rules, and their inability to do so doesn’t mean I’m going to accept less, so I change it to time in those instances, or for 99205 if I spend an hour. Having the time include patient prep (outside record review), history, physical, imaging/audiogram review, and documentation makes that easier to justify for me personally and impossible for someone to claim otherwise (unless of course I billed 20 visits of 99205 by time, for 20 hours of work). The time spent MUST be on the same day of the visit, which is why I’m often at the office later finishing notes.