Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingMedium
A medical assistant is reviewing a patient's medical record for a visit where the patient presented with symptoms of acute bronchitis. The physician's documentation includes 'chief complaint,' 'history of present illness,' 'review of systems,' and 'physical examination.' Which of the following components is missing to meet the typical requirements for an Evaluation and Management (E/M) service?
- AAssessment and Plan
- BAdvanced Directives Discussion
- CMedication Reconciliation
- DPast, Family, and Social History (PFSH)
Show answer & explanationAnswer & explanation
Correct answer: A. Assessment and Plan
The standard components for an E/M service include the History (Chief Complaint, HPI, ROS, PFSH), Examination, Medical Decision Making (Assessment and Plan), and Counseling/Coordination of Care. The Assessment and Plan, which details the physician's diagnosis and treatment strategy, is a critical missing component here.
Why the other options are wrong
- B. Advanced directives discussion is not a standard, required component for every E/M service documentation, unlike the Assessment and Plan.
- C. Medication reconciliation is often done but is not a core, standalone component of E/M documentation like the Assessment and Plan.
- D. PFSH is part of the History component, and while important, the 'Assessment and Plan' is a distinct and crucial E/M component that is missing.
E/M Documentation Components
Key elements required in a patient's medical record to support the level of Evaluation and Management (E/M) service billed.
- History (HPI, ROS, PFSH)
- Examination (Physical Exam)
- Medical Decision Making (Assessment and Plan)
- Counseling/Coordination of Care (if applicable).
Memory trick: E/M: Every Medical Visit Needs History, Exam, and Decision Making.