Chapter 11 Flashcards
Most frequently reported section in the CPT and is located first in the manual
E/M section
Types of services rendered
Office visits, hospital visits, and consultations
The assignment of codes from the E/M section is determined by three factors
- place of service
- type of service
- patient status
Why are the place/type of service and patient status important in coding procedures and services in this section?
Place and type of service have an obvious impact on the complexity and cost of patient treatment
Place of service explains
the setting
Types of services include
consultations, admissions, office visits, prolonged services, etc.
define consultation
request to obtain an opinion or advice about a diagnosis or management option from another physician or other appropriate source
define admission
attention to an acute illness or injury that results in admission to a hospital
define office visit
face-to-face encounter physician and a patient that allows for primary management of the patient’s health care status
Four patient status types consist of
new patient
established patient
outpatient
inpatient
Patient who has not received professional service in the past three years from the physician now providing services or from another physician with the exact same specialty and subspecialty who is in the same medical group as that physician
new patient
Why is the treatment of a new patient more labor intensive for physicians and staff than treatment of an established patient?
New patients require more extensive workups to determine their current medical status
Any patient not classified as as new
established patient
What differences would you expect in the way third-party payers process claims for new and established patients treated for the same condition during an office visit?
New patients require a higher level of service than do established patients, a higher level of reimbursement would be made for treatment of the new patient than for treatment of the established patient.
Patients that have not been formally admitted to a health care facility. Treated in a clinic, a same-day surgery center, or in a hospital under observation status
Outpatient
When are inpatient services coded?
Third-party carriers prohibit billing for both the original outpatient and subsequent inpatient services when delivered on the same day
Patients who have been formally admitted to a health care facility including a hospital or nursing facility
Inpatient
During inpatient visits, the physician may
admission orders, request consultations, order any services or procedures required to meet the patient’s immediate needs following admission.
Must the admitting physician be present at the health care facility during the admission to bill for initial inpatient services required by the patient?
No. These services may be provided at another facility
Dictates admission orders, dictates history and physical examinations, requests consultations, and orders services and procedures
attending physician
Levels of E/M services are based on
documented evidence found in the patient’s medical record of the nature of the presenting problem, and amounts of skill, effort required or assumed, time, responsibility, and medical knowledge used by the physician to provide service to the patient
foundation for the level of service
nature of the presenting problem
How would you expect the E/M level to change if a physician’s assistant provided a service, rather than the physician?
A physician’s assistant has less medical knowledge and less responsibility than the physician does. As a result, compensation may be less when services are performed by a PA
What is important when determining reimbursement for E/M services and procedures
level of service is the main consideration
The greater the level of each key component or contributory factor required to treat a patient, the ____ the level of service coded
higher
Key components are
history, examination, and medical decision making
Contributory factors are
conditions that help the physician determine the extent of the history, examination, and decision making required to treat the patient
Four contributory factors used are
counseling, coordination of care, nature of the presenting complaint, and time
The nature of the presenting complaint will (2)
- determine the need for counseling and coordination of care and whether time is a factor to be considered
- influence the extent of history, examination, and decision making required
Four elements of a history
- chief complaint
- history of present illness
- review of systems
- past, family, and/or social history
Why is it important to have the CC stated in the patient’s own words?
When stated in the patient’s own words, the C is an unaltered account of the reason for the visit
History of Present Illness consists of
subjective information provided by the patient
History of Present Illness is a
chronological description of how the patient’s present illness developed from the first sign and/or symptom or from the previous encounter to the present
History of Present Illness includes
location, quality, severity, duration, timing, context modifying factors, and associated signs and symptoms
HPI is ordinarily obtained as part of a
dialogue between patient and physician
Who must document the HPI?
the provider
quality
description of the pain or symptom
quality includes
sharp, throbbing, burning, constant, dull, and squeezing
duration
how long has the pain been present
severity
is the pain intense, moderate, mild
location
specific location of pain
severity
progression from onset to current time frame
timing
when it occurs – continuously, at night, in the morning –can also mean the frequency of when it occurs
differences in timing may suggest
different diagnoses and treatment plans
context
the circumstances in which the CC occurs – when does it hurt most or is there correlation to a specific activity
modifying factors
the circumstances that make the CC better or worse
determining the level of history: brief and extended
details required to use the category
determining the level of history: brief
1 to 3 elements are in the notes
determining the level of history: extended
4 or more elements in the notes
ROS definition
a thorough inventory of anatomical body systems obtained through a series of question designed to identify signs and symptoms the patient may be experiencing
Why is the ROS needed?
Patients may be so focused on their CC that they overlook other signs and symptoms that could be important to the diagnosis and treatment
ROS is the
series of questions the physician asks or reviews in the patient’s medical record when trying to identify signs and/or symptoms the patient may be experiencing or has experienced
the extent of the ROS depends on
the CC
Medical necessity for the number of ROSs inventoried must be
implied or documented
Systems (14)
- constitutional symptoms
- ophthalmologic
- otolaryngologic
- cardiovascular
- respiratory
- gastrointestinal
- genitourinary
- musculoskeletal
- integumentary
- neurological
- psychiatric
- endocrine
- hematologic/lymphatic
- allergic/immunologic
Problem-pertinent ROS includes
the patient’s responses for the system related only to the problem – 1 system is evaluated by the physician in the ROS
