What are the three key components of an E/M code?

• A. History, examination, and medical decision making
• B. History, review of systems, and physical examination
• C. Medical decision making, patient satisfaction, and billing
• D. Physical examination, medical records, and coding guidelines

Answer: (A)

The main concept here is understanding what determines the level of an E/M (Evaluation and Management) service. The level is based on three elements: the patient’s history, the physician’s examination, and the complexity of medical decision making.

History covers the information gathered about the patient’s present illness and past health, including the history of present illness, review of systems, and past, family, and social history. The examination is the physician’s hands-on assessment and findings from examining the patient, documented as the extent of the physical exam across relevant body systems. Medical decision making gauges how complex the patient’s condition is to diagnose and manage, considering the number of problems, the amount and complexity of data reviewed (tests, records), and the risk of complications or morbidity.

Other options mix in elements that aren’t considered a core triad for determining E/M levels, such as patient satisfaction, billing, or internal resources like medical records or coding guidelines. They either fall outside the three essential components or are part of the process but not the determining factors for the E/M code level itself.

So, the best answer reflects the trio: history, examination, and medical decision making.