What are the three key elements in selecting the appropriate complexity of the E&M codes?

• A. History, physical, and decision making
• B. History, examination, and medical decision making
• C. History, lab, and decision making
• D. History, test, and medical decision making

Answer: (B)

The key idea is that the level of E&M code complexity is determined by three elements: the history, the examination, and the medical decision making involved in the encounter.

History reflects how much information the clinician gathers about the patient’s current problems and past history, including elements like the patient’s symptoms, review of systems, and past medical, family, and social history. The examination measures how thoroughly the clinician physically assesses the patient, from a focused check to a comprehensive head-to-toe exam. Medical decision making looks at how complex the diagnostic and management tasks are, including the number of possible diagnoses, the amount and complexity of data the clinician reviews, and the risk of complications or morbidity associated with the chosen treatment plan.

Choosing a code level is based on these three areas, with time sometimes used as a separate determinant in specific scenarios. That makes the option listing history, examination, and medical decision making the correct choice. Other options mix terms like “physical,” “lab,” or “test” that aren’t the primary trio used to set E&M complexity.