Choose two of the six constituent elements that comprise an ...

[LaDunn]

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.
 
  What will be an ideal response?

Question 2

Please explain why the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services are so important for evaluation and management services.
 
  What will be an ideal response?

[lou]

Answer to Question 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.

Answer to Question 2

The 95 and 97 DGs provide specific guidelines for the documentation of evaluation and management services. These guidelines include content of service, which is one of the six constituent elements that makes up an evaluation and management service. The 1995 DGs are 16 pages long and, because there were unanswered questions about the physical examination, the 1997 DGs were written. The 1997 DGs are 49 pages long.