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CMS elements

  1. #1
    Default CMS elements
    Medical Coding Books
    Does anyone know what 3 elements must be present in a document to meet CMS's guidelines for using a document?

    Thanks!

  2. #2
    Location
    North Carolina
    Posts
    3,126
    Default
    History, examination and medical decision making are the key components in selecting the level of E/M services. Below are all the components:

    • history;
    • examination;
    • medical decision making;
    • counseling;
    • coordination of care;
    • nature of presenting problem; and
    • time.

    Is this what you're looking for?

    https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp

  3. #3
    Default
    The question is so vague. It literally only says what 3 elements must be present. It doesn't even say specifically for an E/M service. Is there something else in CMS that states maybe items like site of service, medical necessity, etc? Maybe things like that?

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