Which part of the medical record is most relevant to determining the Evaluation and Management code used for billing?

• A. History and Physical
• B. Progress Notes
• C. Lab Reports
• D. Imaging Results

Answer: (A)

The key idea is that E/M codes are determined by what’s documented about the patient’s history, the physical examination performed, and the level of medical decision making. The History and Physical portion of the record provides the actual history elements (such as the chief complaint, history of present illness, and review of systems) and the clinician’s documented examination findings. These elements form the core basis for judging the level of history and the extent of the exam, which are central to setting the E/M code, often in combination with the complexity of medical decision making.

Labs and imaging results do influence medical decision making, since data gathered can add to the data complexity, but they are not the primary source that defines the level of service. Progress notes describe ongoing care and plans, but the specific documented history and physical findings are what most directly determine the coding level.