What are the three key components of E/M coding based on the 1995 and 1997 documentation guidelines?

The three key components of Evaluation and Management (E/M) coding, as defined by the 1995 and 1997 documentation guidelines, are history, physical exam, and medical decision making. These components are essential for determining the level of service provided and are integral in accurately documenting patient encounters for billing purposes.

History refers to the patient's medical history, including the chief complaint, history of present illness, and past medical, family, and social histories. The physical exam involves a systematic examination of the patient’s body, which helps in assessing the patient's health status. Medical decision making encompasses the complexity of establishing a diagnosis and/or selecting the management options, which takes into account various factors such as the number of problems addressed, data reviewed, and the risk to the patient.

These components collectively provide the framework needed for E/M coding, ensuring that all necessary information is captured to support the level of healthcare service rendered, which is crucial for reimbursement and compliance with documentation standards.