What must be documented during an encounter if the E/M code is selected based on time?

When selecting an Evaluation and Management (E/M) code based on time, it is crucial to document the patient's complaints and progress in detail. This is because one of the key components of using time-based coding involves not only the total time spent with the patient but also the context of that time.

Specific documentation of the patient's complaints provides a clear understanding of the clinical reasons for the visit and shows the medical decision-making process involved. It also gives insight into how the time was utilized in addressing the patient's concerns, interpreting test results, or planning further treatment. Therefore, comprehensive documentation emphasizes the medical necessity of the services provided and supports the E/M coding, ensuring proper billing and compliance with coding guidelines.

Other options do not capture the essential elements required for thorough documentation when coding based on time. While total time and course of treatment may be relevant to the visit, they do not replace the need for detailed notes on the patient's complaints and progress, which are critical for substantiating the encounter's medical necessity and the chosen E/M code. Patient insurance information is unrelated to clinical documentation requirements.