established patients

My question is regarding choosing the key components for an established patient.


I usually go with the exam and medical decision to get the appropriate level.

Can I switch from patient to patient and use HPI and MDM or HPI and exam? Or do I need to be consistent for each patient?

Thanks

re: established patients-still looking for help on this one

re: established patients

The CPT® book says only 2 out of the 3 key components are required for an established patient. It doesn't specify which 2 of the 3 are necessary; however, it is wise to try to use MDM to justify the medical necessity.