The process of coding starts with examining whether one deals with an established client or new client. A client who has not been given any special services from the particularity within a time frame of last 3 years is new client. On the other hand, a client who has been given special service from the doctor or any other qualified professional in the same practice group within a period of 3 years is known as an established client. For the case of a new patient, it is a requirement that for adequate coding, all three components are documented well. In another way, the codes usually requires 2 to 3 components in case of established patient. The exceeding practice is documentation of standard of care for the presentation of problem and then choosing the code that suitably indicate the services offered and documented.
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