What are the three key factors in selecting an E/M code?

The selection of an E/M (Evaluation and Management) code is primarily determined by three key factors: history, examination, and medical decision making. These components reflect the complexity and extent of the services provided during a patient encounter.

History involves understanding the patient's medical background, including presenting problems, past medical history, family history, and social history. This information helps establish a context for the current visit.

Examination pertains to the physical examination conducted by the healthcare provider, assessing the patient's current health status and identifying any potential issues that need to be addressed.

Medical decision making is critical as it involves the complexity of establishing a diagnosis or treatment plan based on the information gathered during the history and examination. It considers factors like the number of diagnoses, the amount and complexity of medical data reviewed, and the risk of complications associated with patient management.

Together, these elements form the basis for accurate coding and billing, ensuring appropriate reimbursement for the services rendered based on the level of care provided. Understanding how these factors interplay is essential for healthcare professionals involved in revenue cycle management.