Certified Professional Medical Scribe (CPMS)

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A scribe is documenting for a physician who is evaluating a new patient. According to the 2023 E/M coding guidelines, which of the following documented elements is most critical for determining the appropriate level of service based on Medical Decision Making (MDM)?

The number of body systems reviewed in the Review of Systems (ROS). The comprehensiveness of the physical examination performed. The number and complexity of problems addressed, and the amount of data reviewed. The total face-to-face time spent with the patient.

Correct Answer:

The number and complexity of problems addressed, and the amount of data reviewed.

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