Choose two of the six constituent elements that comprise an evaluation and management service, and explain how these two selected constituent elements are important for thorough medical documentation and an evaluation and management service

Question

What will be an ideal response?

Answer 1

Any combination of the definitions with rationale for the interrelation between the two definitions in relation to evaluation and management service.
content of service – the three elements that are considered the building blocks for evaluation and management services: history, physical examination, and medical decision making;
nature of the presenting problem – the condition, illness, injury, complaint or other reason for which the patient has presented to the healthcare facility for the evaluation and management service;
place of service – the identifying term used to specify the facility or location where the evaluation and management service visit occurs, such as a clinic office, an emergency room, etc;
type of service – identification of the extent of clinical experience between the patient and the clinician or facility;
typical time – some evaluation and management service requirements are based on time in minutes, while other requirements use a "per diem" or calendar day guideline. Other guidelines list the time as a block of time during which a specific visit typically can be performed, while certain E/M services do not recognize time as a requirement at all;
unique listed code – the specific evaluation and management service code listed in the CPT book that identifies the performed and documented evaluation and management service.