What are key components of Eval and Management E/M?

• A. Chief Complaint, History of Present Illness, and Past Medical History
• B. History, Physical Examination, Medical Decision Making
• C. Provider's Assessment, Treatment Plan, Follow-Up
• D. Laboratory Data, Imaging, and Therapeutic Interventions

Answer: (B)

Eval and Management (E/M) coding centers on three core elements: the history obtained from the patient, the physical examination performed, and the medical decision making involved in the case. The history captures what brought the patient in, including the present illness or symptoms and relevant past, family, and social history, often organized as the history of present illness, review of systems, and past medical/social/family history. The physical examination is the clinician’s hands-on assessment of the patient, typically performed by system or body area, to identify objective findings. Medical decision making reflects how complex the case is: the problems being addressed, the data reviewed (labs, tests, records), and the risks of potential complications or changes in management.

This combination is the best answer because it reflects the standardized framework used to determine the level of E/M service. Other options mix elements that are part of the clinical narrative or data used in decision making but do not represent the three primary components that drive E/M coding. For example, relying only on parts of the history omits the required physical examination and decision making; listing data types like labs or imaging refers to data sources rather than the triad itself; and the Assessment and Plan, while essential to documentation, are not the three elements that define the E/M level.