The Examination Is The ____ Portion Of The E/M Service

Evaluation and Management (E/M) services are an integral part of health care and involve components of both history taking and physical examination. In terms of an E/M service, the physical examination is the portion of the service that takes the longest and requires the greatest amount of skill.

What Is A Physical Examination?

A physical examination is a comprehensive assessment of a patient’s health. During the physical examination, the clinician will observe and assess many different parts of the patient’s body, such as taking vital signs, checking for inflammation, assessing organ systems, and evaluating range of motion for joints and muscles. The examination is also the component of the E/M service in which diagnosis codes are assigned.

Importance of The Physical Examination in an E/M Service

The physical examination is an essential component of an E/M service and is often the portion of the service that takes the longest. It is also the component of the E/M service in which diagnosis codes are assigned and levels of service are determined. The American Medical Association (AMA) has published CPT E/M Documentation Guidelines for 2021, which provide specific guidance for how clinicians should document and code E/M services.

Conclusion

The physical examination is the most important and time-consuming portion of an E/M service. Clinicians must ensure that their physical examination is thorough and accurate in order to determine the appropriate level of service and to assign the E/M service correctly. The AMA has published CPT E/M Documentation Guidelines to provide guidance to clinicians on how to correctly document and code E/M services.