what are the three components that present in every patient case except counseling encounter or time based codes

The three components that are present in every patient case, except counseling encounters or time-based codes, are:

1. History: This component involves gathering information about the patient's medical history, including the chief complaint, present illness, past medical history, family history, and social history. To document the history component, healthcare professionals typically ask the patient open-ended questions to elicit detailed information.

2. Examination: This component involves conducting a physical examination of the patient. Healthcare professionals evaluate the patient's body systems, perform appropriate tests, and document their findings. The examination component may include general observations, vital signs, inspection, palpation, percussion, and auscultation.

3. Medical decision making: This component involves analyzing the information obtained from the history and examination to formulate a diagnosis or treatment plan. Healthcare professionals consider the complexity of the patient's problem(s), the amount and/or complexity of data reviewed, and the risk of complications or morbidity. Documentation of medical decision making should be thorough and include the clinical thought process.

It is important to note that these three components are essential in the evaluation and management of most patient cases. However, for counseling encounters or time-based codes, the main focus is on the time spent by the healthcare professional providing counseling services, rather than the history, examination, or medical decision making components.