When coding for established patients, how many key components must be considered?

When coding for established patients, two key components must be considered to determine the level of service provided during the visit. These key components typically include the patient's history and the examination performed by the physician, along with the decision-making complexity involved in the patient's care.

In coding for established patients, these components help healthcare providers align their documentation with the appropriate Current Procedural Terminology (CPT) codes, which directly impact billing and reimbursement. Evaluating these two components allows for a more accurate reflection of the patient's visit, ensuring that appropriate resources and time are accounted for in the coding process. This method ensures that patients receive the correct level of care, and facilitates proper billing for the services rendered.

Understanding that the specific details of the history and examination can vary widely in terms of complexity and comprehensiveness is important, making it essential for coders and healthcare professionals to be attentive to these key components when determining the correct coding for established patients.