Which section of the medical record is used to determine the correct Evaluation and Management code used for billing and coding?

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Multiple Choice

Which section of the medical record is used to determine the correct Evaluation and Management code used for billing and coding?

Evaluating and coding for E/M services relies on the data documented about the patient’s history and the physical examination. The History and Physical section captures the full history (history of present illness, review of systems, past medical, family and social history) and the detailed physical findings from the examination. This information directly supports the level of service billed, especially for new patient visits, because more extensive history and a broader exam justify higher codes. The assessment and plan show the diagnoses and management decisions, and progress notes provide updates, but they don’t by themselves supply the complete history and exam data used to determine the code. The plan of care isn’t the factor used to set the E/M level. So the History and Physical is the section that most determines the correct E/M code.

Evaluating and coding for E/M services relies on the data documented about the patient’s history and the physical examination. The History and Physical section captures the full history (history of present illness, review of systems, past medical, family and social history) and the detailed physical findings from the examination. This information directly supports the level of service billed, especially for new patient visits, because more extensive history and a broader exam justify higher codes.

The assessment and plan show the diagnoses and management decisions, and progress notes provide updates, but they don’t by themselves supply the complete history and exam data used to determine the code. The plan of care isn’t the factor used to set the E/M level. So the History and Physical is the section that most determines the correct E/M code.

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