Which key components must be considered when a provider is selecting a visit level?

When selecting a visit level for a patient encounter, it is essential to consider the components of history, exam, and medical decision making. Each of these elements contributes to determining the complexity of the visit and influences the coding process for billing purposes.

The history component involves understanding the patient's medical history, the presenting problem, and any relevant social or family history. It must be comprehensive enough to inform the provider's diagnostic process and treatment plan.

The examination aspect refers to the physical examination conducted by the provider, which assesses the patient's current health status. The extent and thoroughness of the exam can vary based on the patient's condition and the level of care needed.

Medical decision making is crucial as it evaluates the complexity involved in formulating a diagnosis and creating a treatment plan. It accounts for factors like the number of potential diagnoses, the management options being considered, and the risk of complications or morbidity associated with the patient's conditions.

By combining these three key components, providers can accurately select the appropriate visit level that reflects the complexity and resource intensity of the healthcare service provided to the patient.