Which elements are typically required to support an E/M code?

Which elements are typically required to support an E/M code?

• A. Thorough history, exam, medical decision making (or time-based criteria), and documentation supporting medical necessity and level of service.
• B. The patient’s satisfaction scores from the visit.
• C. The physician’s license number and credentials.
• D. The clinic’s location and hours of operation.

Answer: (A)

Understanding how E/M coding is determined: the level of service is driven by the documentation of history, the extent of the examination performed, and the complexity of medical decision making, with time-based criteria used when appropriate. The chart must clearly show medical necessity for the visit and the level of service reported, so the code matches the work performed. The other options don’t affect the E/M code: patient satisfaction scores aren’t a coding factor, nor are the physician’s license numbers or the clinic’s location and hours. If time is the determinant, include the total time spent and the counseling/coordination time in the record to justify the level.

Understanding how E/M coding is determined: the level of service is driven by the documentation of history, the extent of the examination performed, and the complexity of medical decision making, with time-based criteria used when appropriate. The chart must clearly show medical necessity for the visit and the level of service reported, so the code matches the work performed. The other options don’t affect the E/M code: patient satisfaction scores aren’t a coding factor, nor are the physician’s license numbers or the clinic’s location and hours. If time is the determinant, include the total time spent and the counseling/coordination time in the record to justify the level.