Please Give An Example of Proper documentation for CPT® 99310

Please give an example of what documentation is needed to bill a 99310

re: Please Give An Example of Proper documentation for CPT® 99310

Watch out because this service code is often billed without documentation of medical necessity. Many times this code is billed at a higher level than was substantiated by the documentation. Did the physician document medically complex care rendered? The patient may be unstable and require high complexity MDM. The diagnosis code(s) should convey the severity of the patient's condition(s). If the medical decision making did not support high complexity, the question will be "why was code 99310 billed".