Question

The level of E/M service is based on?

1) documentation
2) 3 Key components
3) contributing factors
4) all of the above

Answer 1

The level of E/M service is determined by documentation, the 3 key components (history, examination, and medical decision making), and contributing factors. Policies must balance treatment costs, patient quality of life, and privacy risks, and should address issues of record accuracy, patient quality of life, and protection of privacy.

Step-by-step explanation:

The level of Evaluation and Management (E/M) service is based on several factors. According to medical coding guidelines, E/M levels are determined by the complexity of the services performed and are typically categorized by the type and level of encounter.

Specifically, the level of service is based on documentation, the 3 key components (which are the history, examination, and medical decision making), and contributing factors such as the amount of time spent with the patient and the complexity of the medical decision making.

Ensuring accuracy in health records is essential, and the development of policies must consider the balance between the costs of treatments and diagnoses, the quality of life for patients, and the risks to individual privacy.

Three questions that should be addressed when creating these policies include:

1. How can we ensure that health records accurately reflect the complexity and necessity of services rendered to justify treatment costs?
2. What measures should be taken to maintain or improve patient quality of life through healthcare services?
3. How can we protect patient privacy while still allowing for the necessary use of personal health information in medical decision-making?