When coding for an established patient, what is an essential element to consider?

When coding for an established patient, it is essential to consider whether the patient has had a previous examination. This is crucial because the history of prior evaluations significantly impacts the coding process. Established patients are those who have received professional services from the provider or another provider of the same specialty who belongs to the same group practice within a defined time frame, typically three years. Understanding the patient's medical history, including previous examinations, helps determine the complexity of the current visit, appropriate evaluation and management (E/M) coding levels, and any relevant diagnoses. Accurately capturing the continuity of care and the nature of the follow-up based on previous evaluations is vital in reflecting the patient’s ongoing health needs.

The other factors listed, such as financial background, time since the last visit, and the patient’s opinion on treatment, do not directly influence the coding process as strongly as the record of previous examinations. While these elements can be relevant for broader practice management and patient interactions, the core requirement for coding focuses on the patient's clinical history and previous encounters with the provider.