Question

When coding for visits of new patients, the key component that must be included to document the correct level of evaluation and management (E/M) are:

A. History, physical and medical decision making
B. Physical exam and medical decision making
C. History and physical exam
D. Age, DX, and medical decision making

Answer 1

The key components for documenting an E/M visit for a new patient are History, physical exam, and medical decision making. These components support accurate medical coding and record-keeping while respecting cost, quality of life, and privacy concerns.

Step-by-step explanation:

When coding for visits of new patients, the key components that must be included to document the correct level of evaluation and management (E/M) are History, physical exam, and medical decision making. These components are essential to ensure an accurate and complete medical record that reflects the complexity of the visit and establishes the medical necessity for the services provided. When developing policies related to health records, one must closely consider the balance between the costs of treatments and diagnoses, patient quality of life, and risks to individual privacy.