Bucks Ch 11 E/M services Flashcards
Which Appendix lists all the modifiers that are used to alter or modify codes in the CPT manual?
Appendix A
What are the the 6 sections of the CPT manual
■ Evaluation and Management 99202-99499
■ Anesthesia 00100-01999
■ Surgery 10004-69990
■ Radiology 70010-79999
■ Pathology and Laboratory 80047-89398, 0001U-0419U
■ Medicine 90281-99607
After the section what are the additionl divisions of categerys from genral to the most specific?
Section. At the top of the page, the word “Surgery” indicates the section.
Subsection. Also at the top of the page, the phrase “Integumentary System” indicates the subsection.
Subheading. The words “Skin, Subcutaneous and Accessory Structures” indicates the subheading.
Category. The words “Incision and Drainage” indicates the category.
Unlisted service or procedure codes end in what numbers?
99
ex.33999
Code assignment in the E/M section varies according to what three factors?
- Place of service
- Type of service
- Patient status
What are examples of place of service?
A physician’s office, hospital, emergency department, nursing home, and so on.
What is the 2nd factor for code assignment in the E/M section of the CPT manual?
Type of Service
4 examples of types of service are:
■ Consultation is a written or verbal request from one provider/physician to another to obtain an opinion and/or advice about a diagnosis or management options.
■ Admission is attention to an acute illness or injury that results in admission to a hospital.
■ Newborn care is the evaluation and determination of care management of a newly born infant.
■ **Office visit **is a face-to-face encounter between a physician and a patient to allow for primary management of the patient’s health care status.
What is the 3rd factor for code assignment in the E/M section of the CPT manual?
Patient Status
What are the four types of patient status for assignment of code in the E/M section of the CPT manual?
■ New patient is one who has not received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years.
■ Established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years.
■ Outpatient is one who has not been formally admitted to a health care facility or a patient admitted for observation.
■ Inpatient is one who has been formally admitted to a health care facility.
The elements of ____ ____ ____ focus on the elements that affect the management of a patient’s condition that include:
1. number and complexity of problems addressed
1. amount and/or complexity of data reviewed
1. risk of complications and/or morbidity or mortality of patient management.
Medical decision making (MDM)
To qualify, for a Medical decision making (MDM) status how many elements must be met or exceeded?
two of the three elements of MDM must be met or exceeded.
____ may be used to report office or other outpatient services instead of MDM
Time
What does the following information represent?
- Number of diagnoses. The options can be
minimal, low, moderate, or high. - Amount and/or complexity of data to review. The data can be
minimal or none, limited, moderate, or extensive. - Risk of complication or death if the condition goes untreated.
Risk can be minimal, low, moderate, or high.
3 elements of MDM or Medical Decision Making
Explain the 4 complexity levels for Medical decision making
■ Straightforward
■ Low
■ Moderate
■ High
Straightforward decision making: Minimal diagnosis and management options, minimal or none for the amount and complexity of data to be reviewed, and minimal risk to the patient of complications or death if untreated.
Low-complexity decision making: Limited number of diagnoses and management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.
**Moderate-complexity decision making: **Multiple diagnoses and management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.
High-complexity decision making: Extensive diagnoses and management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.
T or F
E/M guidelines are for services that require a face-to-face encounter with the patient and/or family/caregiver.
True
What is the time limit to qualify as a new or established patient
3 years
Are you a new patient if you go to another doctor in the same practice with the same specialty but different subspecialties
Yes, you have to see the same specialty and subspecialty to be considered a new or established patient.
is it considered the same specialty and subspecialty:
Where a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, and a patient meetds with advanced practice nurses and physician assistants instead of their doctor?
Yes
A ____ ____ member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service.
clinical staff
A ________________ is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service.
“physician or other qualified health care professional”
physician or other QHP
Selecting the appropriate level of E/M services is based on what 2 things?
- The
level of the MDM as defined for each service, or - The
total time for E/M services performedon the date of the encounter.
When evaluating a problem-
Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented __does/or does not__qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
does not
A ________is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
Problem
straightforward minimal MDM problem elements (level 2)
A ________problem may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision.
____-____ or ________problem is a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
Minimal problem
Self-limited or minor problem
Low/Moderate/High MDM Problem depending on quantity and catagory
____,____ ____ A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). “Stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
Stable, Chronic illness
Low/Moderate/High MDM Problem depending on quantity and catagory
____, ____ ____ or ____ is a recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. *A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. *
Acute, uncomplicated illness or injury
Low/Moderate/High MDM Problem depending on quantity and catagory
____, ____ ____ is a problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
Stable, acute illness
Low MDM Problem (level3)
Acute, uncomplicated illness or injury requiring ____ ____ or ____ ____ ____ A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.
hospital inpatient or observation level care
Moderate/High MDM Problem depending on quantity and catagory
____ ____ with exacerbation, progression, or ____ ____ of ____: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.
Chronic illness with exacerbation, progression, or side effects of treatment
level 4 Moderate MDM Problem
____ new problem with ____ prognosis: A problem in the differential diagnosis (most likely cause of sypmtoms) that represents a condition likely to result in a high risk of morbidity without treatment.
Undiagnosed new problem with uncertain prognosis
level 4 Moderate MDM Problem
____ illness with ____ symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. Systemic symptoms may not be general but may be single system.
Acute illness with systemic symptoms
High level 5 MDM problem
Chronic illness with ____ ____, progression, or ____ ____ of ____: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
Chronic illness with sever exacerbation, progression, or side effects of treatment.
level 4 moderate MDM problem
____, ____ injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.
Acute, complicated injury
High level 5 MDM problem
Acute or chronic illness or injury that poses a ____ to ____ or ____ function An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment.
Acute or chronic illness or injury that poses a threat to life or bodily function
MDM amount and complexity of data to be reviewed and analyzed
Elements of analyzed and reviewd data used in the thought processes for diagnosis, evaluation, or treatment.
review notes from previous or external drs, independant historian, tests/labs, discussion
MDM amount and complexity of data to be reviewed and analyzed
____ data requires 2 points of:
Review of external note(s)
(1 pt per unique source)
Review of test results
(1 pt per unique test)
Ordering tests
(1 pt per unique test)or Assessment requiring a independent historian
Limited Data
MDM amount and complexity of data to be reviewed and analyzed
____ data requires 3 points of:
Review of external note(s)
(1 pt per unique source)
Review of test results
(1 pt per unique test)
Ordering tests
(1 pt per unique test)
Assessment requiring a independent historian
or
Independent interpretation of test performed by another
or
Discussion of management or test interpretation with another.
Moderate Data
MDM amount and complexity of data to be reviewed and analyzed
____ data requires 3 pointsand 2 sections of:
Review of external note(s)
(1 pt per unique source)
Review of test results
(1 pt per unique test)
Ordering tests
(1 pt per unique test)
Assessment requiring a independent historian
and/or
Independent interpretation of test performed by another
and/or
Discussion of management or test interpretation with another.
Extensive data
MDM amount and complexity of data to be reviewed and analyzed
____ are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple tests is defined in accordance with the CPT code set. For the purpose of data reviewed and analyzed, pulse oximetry is not a test.
Tests
MDM amount and complexity of data to be reviewed and analyzed
____ ____ is a collection of measurements that track a person’s physical and mental state through biosensers. It can include measurements of heart rate, breathing, skin temperature, and brain activity
Physiological data
MDM amount and complexity of data to be reviewed and analyzed
A ____ ____ is when multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is a physician or other qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.
unique test
MDM amount and complexity of data to be reviewed and analyzed
____ requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).
Discussion
MDM amount and complexity of data to be reviewed and analyzed
An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It does not include translation services. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.
Independent historian(s)
MDM amount and complexity of data to be reviewed and analyzed
____ ____ an appropriate source includes professionals who are not health care professionals but may be involved in the management of the patient (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.
Appropriate source:
MDM Risk of Complications Morbidity or Mortality of Patient Mana
____ A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
Morbitity
MDM Risk of Complications Morbidity or Mortality of Patient Mana
Examples of ____ Risk
* Rest
* Elastic bandages
* Superficial dressings
Minimal
MDM Risk of Complications Morbidity or Mortality of Patient Mana
Examples of ____Risk
* OTC drugs without mention of complications
* Minor surgery w/o identified risk factors
* PT/OT Therapy
* IV fluids w/o additives
Low
MDM Risk of Complications Morbidity or Mortality of Patient Mana
Examples of ____ Risk
* Prescription drug management
* Secision regarding minor surgery with identified patient or procedure risk factors
* Decision regarding elective major surgery without identified patient or procedure risk factors
Moderate
