Which of the following is a primary factor for selecting an evaluation and management (E/M) visit level?

• A. Number and complexity of problems addressed
• B. Amount of time spent with the patient
• C. Patient satisfaction
• D. Type of insurance

Answer: (A)

The main factor guiding an E/M visit level is the number and complexity of problems addressed. This drives the amount of medical decision making involved—the risks considered, data reviewed, and management options chosen—so encounters with more problems or with more complex problems require a higher level. Time spent with the patient can influence the level when coding is based on total time, but in the typical decision-making framework, problem count and complexity are the primary determinant. Patient satisfaction and insurance type don’t determine the coding level.