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doi: 10.1016/j.jpeds.2009.12.033

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Step 4: Document the Encounter Record everything needed to support the code in the medical record: Chief complaint and relevant history Examination findings, to the extent medically appropriate Assessment and plan Total time, if billing by time Telehealth modality and POS code, if applicable Step 5: Select Appropriate Modifiers Append Modifier 25 if billing 99212 on the same day as a procedure