Take the challenge. B—The presenting problem(s) is what is evaluated during the history and examination by the provider. The chief complaint is in the patient’s own words or is a follow-up for his or her current condition. The history of present illness, along with the review of systems, usually guides the provider through the examination….

Evaluation & Management Documentation Quiz What element drives an evaluation and management (E/M) visit? The chief complaint in the patient’s own words of why he or she is in the practice for that date of service. The presenting problem(s) being discussed with the physician for that patient during the visit. The examination performed on the…