Which components are part of the key evaluation and management (E/M) codes?

Prepare for the Current Procedural Terminology (CPT) Exam. Study with flashcards and multiple choice questions, each question has hints and explanations. Get ready for your exam today!

The correct answer includes the history of present illness, review of systems, and past family/social history as part of the key components of evaluation and management (E/M) codes. E/M coding is primarily structured around three core components: the history, examination, and medical decision-making.

The history component, which includes the history of present illness, is crucial for understanding the patient's current health issues. The review of systems helps in capturing additional symptoms that may not be directly related to the chief complaint. Furthermore, the past family/social history provides context about potential hereditary conditions and the patient’s lifestyle, which can influence their health.

The other options either present incomplete components or are not directly related to the essential elements of E/M coding. For example, while time spent with the patient and laboratory tests may be relevant in certain contexts, they do not constitute the key components required for E/M code selection. Similarly, while physical examination is vital, it is only one part of the broader framework and does not encompass the full set of necessary elements without the supporting history and decision-making criteria.

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