Which sections of the medical record are used to determine the correct Evaluation and Management code for billing?

• A. History and Physical
• B. Lab results
• C. Imaging reports
• D. Medication list

Answer: (A)

Understanding Evaluation and Management (E/M) coding hinges on how much patient history is documented and how extensive the physical examination is, along with the level of medical decision making. The sections that determine the E/M code are the history and the physical examination. The history captures the patient’s current symptoms, past health, and social factors, while the physical examination documents the findings across body systems. These components establish the level of service you can bill for.

Lab results, imaging reports, and medication lists are valuable data that can influence medical decision making, potentially pushing the code higher if they add complexity, but they’re not the primary sections used to determine the E/M level. In short, the history and the physical findings drive the coding decision, with data like labs and imaging shaping the decision-making burden.