For new patients, how many components of E/M level determination are required?

For new patients, three components of Evaluation and Management (E/M) level determination are required to accurately assess the complexity of the patient's visit and to ensure appropriate coding for reimbursement. These components are:

1. History - This includes obtaining the patient's medical history, which encompasses the chief complaint, history of present illness, and relevant past, family, and social history.

2. Examination - A physical examination is performed to assess the current health status of the patient. The level of examination can vary from a straightforward check-up to a more comprehensive assessment, depending on the patient's condition and needs.

3. Medical Decision Making (MDM) - This refers to the complexity of the decision-making involved in diagnosing and treating the patient. Higher levels of MDM are required when the clinical situation is more complex, involving multiple diagnosis or complications.

To determine the correct E/M level for a new patient, a provider must document all three components. The requirement of all three components ensures that the coding reflects the full scope of the patient's visit and the healthcare provider's efforts, ensuring compliance with billing standards and proper reimbursement.