What are the components used to measure the level of Evaluation and Management (E/M)?

The correct choice highlights the three fundamental components essential for measuring the level of Evaluation and Management (E/M) visits, which are history, examination, and medical decision-making.

History refers to the thorough account of the patient's health background, which encompasses both the present illness and any relevant past medical history. This component aims to establish the context for the current visit or consultation and evaluates the problem's severity and complexity.

The examination refers to the physical assessment of the patient. This involves the healthcare provider performing specific tests or checks to gather information about the patient’s current health status. The extent or detail of the examination can vary depending on the presenting problem and the provider's clinical judgment.

Medical decision-making encompasses the thought processes involved in diagnosing and treating the patient. This includes evaluating the patient's condition, considering differential diagnoses, and deciding on a treatment plan that could involve referrals, tests, or therapy options. The complexity of medical decision-making is often tied to the number of diagnoses or management options, the amount and complexity of data to review, and the risk of complications and/or morbidity.

When these three components—history, examination, and medical decision-making—are combined, they enable coders and healthcare providers to determine the appropriate level of service for E/M documentation based