Current Procedural Terminology and the Centers for Medicare & Medicaid Services evaluation and management (E/M) guidelines instruct the coder to select the E/M code based on the performance and documentation of the required key components (history, physical examination, and medical decisionmaking, or time if more than 50% of the total face-to-face encounter is spent in counseling or coordination of care). Therefore, if a code requires that 2 of the 3 key components be met, technically the code selection may be based on the level of history and physical examination performed. However, while it might be physician's preference to perform a detailed or comprehensive-level history and physical examination at every visit, only the level of history and examination that is medically necessary to address or treat the condition(s) or problem(s) should be used in the selection of the code. Typically the level of medical decision-making (ie, number of diagnoses and management...

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