Key Components and Contributing Factors, Essay Example

There are many levels of E/M services that can be provided to patients through a particular system and definition of factors and components.  First of all, key components in determining proper E/M services involve three main elements.  These elements are history, examination and medical decision making.  Often, the history can be evaluated or measured by receiving the chief complaint and history of present illness from the patient.  The examination depends greatly upon the physician’s clinical judgment, the history that has been properly evaluated and measured, as well as the nature of the current problem.  Examinations can be measured by conducting general multi-system examinations or a single organ system examination.  Medical decision making is a complex process where the physician or treatment staff determine a diagnosis and select a possible treatment option.  This is measured by the number of possible treatments or options available, the complexity of the current problem, the extent of the family history, and the results of the examinations.

Contributing factors to providing E/M services involve counseling, coordination of care and nature of presenting problem.  Counseling is often a treatment method utilized to work with psychological issues.  The effectiveness of the counseling can be measured by the patient’s involvement and participation in the treatment as well as the receptiveness to other treatment methods being utilized.  E/M services also utilize coordination of care as a contributing factor whereby the methods and treatment plan are properly coordinated.  The coordination of care can be measured by the scheduling and overall face-to-face time that the patient has in the office or any other outpatient setting.  Finally, the nature of the presenting problem is a contributing factor for E/M services because the physician must properly evaluate the extent to which the problem exists and the effectiveness that the treatment has had on alleviating the symptoms.