What are the three elements that determine the level of an Evaluation and Management (E/M) service?

What are the three elements that determine the level of an Evaluation and Management (E/M) service?

• A. History, Documentation, and Billing
• B. History, Assessment, and Therapeutic Intervention
• C. History, Examination, and Medical Decision Making (MDM)
• D. History, Physical Exam, and Clinical Judgment

Answer: (C)

The level of an Evaluation and Management service hinges on three elements: history, examination, and medical decision making. History captures the story the patient provides—the chief complaint, the history of present illness, review of systems, and past, family, and social history. The depth and breadth of this history help determine how much information the clinician gathers and considers, which in turn influences the level. Examination refers to the clinician’s hands-on assessment across body systems. The extent of the physical findings documented—ranging from a focused check to a comprehensive survey—contributes to the overall level as well. Medical decision making reflects the complexity of decisions the clinician must make: the number of diagnoses or management options under consideration, the amount and complexity of data reviewed, and the risk of complications or morbidity. Together, these three components determine the service level; other items like documentation, billing, or purely therapeutic actions aren’t the elements used to set the E/M level. In particular, clinical judgment is involved in MDM, but the explicit determinants are history, examination, and medical decision making.

The level of an Evaluation and Management service hinges on three elements: history, examination, and medical decision making.

History captures the story the patient provides—the chief complaint, the history of present illness, review of systems, and past, family, and social history. The depth and breadth of this history help determine how much information the clinician gathers and considers, which in turn influences the level.

Examination refers to the clinician’s hands-on assessment across body systems. The extent of the physical findings documented—ranging from a focused check to a comprehensive survey—contributes to the overall level as well.

Medical decision making reflects the complexity of decisions the clinician must make: the number of diagnoses or management options under consideration, the amount and complexity of data reviewed, and the risk of complications or morbidity.

Together, these three components determine the service level; other items like documentation, billing, or purely therapeutic actions aren’t the elements used to set the E/M level. In particular, clinical judgment is involved in MDM, but the explicit determinants are history, examination, and medical decision making.