E/M services are a type of medical service provided by physicians and other healthcare professionals. E/M services include evaluation and management of patient’s medical, mental, and social health needs. The level of E/M service is based on three key components:

1. History

The history component of an E/M service includes the information gathered from the patient about their health such as symptoms, prior medical history, family history, medications, allergies, and any other pertinent information. The amount of time spent gathering this information helps to determine the level of E/M service.

2. Examination

The examination component of an E/M service includes the physical exam being done by the physician or healthcare professional. The number and extent of the examinations performed, and the complexity of the diagnosis being considered are important factors that help to determine the level of E/M service.

3. Medical Decision Making

The medical decision making component of an E/M service is determined by the complexity and extent of the data being examined for diagnosis, the complexity of the decision making process, and the amount of time spent by the physician or healthcare professional in analyzing and interpreting the data. This is one of the most important components for determining the level of E/M service.

The level of E/M service is based on all three of these components. A complete evaluation of the patient’s history, examination, and medical decision making can help to determine the correct level of service. The amount of time spent in performing the evaluation is also taken into consideration when determining the level of E/M service.