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
Expanded ROS includes
the patient’s responses for 2 to 9 of the systems
Complete ROS includes
the system(s) noted in the HPI and all additional body systems; at least 10 of the 14 organ systems must be reviewed
Past history is the
patient’s illnesses, operations, hospitalizations, injuries. allergies, current medications, immunizations, and dietary status
Social history is a
set of questions relating to oast and current activities common for the patient’s age
Social history contains
relevant information about living arrangements, other relevant social factors, and social drug/tobacco/alcohol use
Family history includes the
medical events in the patient’s family including diseases that may be hereditary, could put the patient at risk, or are relevant to the patient’s chief complaint
Pertinent PFSH reviews the
history area(s) for the CC. At least 1 item from any of the 3 history areas must be noted
Complete PFSH reviews ____ or all three of the areas, depending on the level of service
2
Established office visits must have
2 of the 3 areas documented
New patient office-visits must have
all 3 areas documented
Initial visits require at least
one item from all three PFSH areas
For subsequent hospital care, followup inpatient consultation, and subsequent nursing facility care, the CPT only requires
an “interval” history, the the PFSH
What is the goal with a problem-focused history?
To obtain detailed information about the CC and the chronology of the development of associated symptoms
Brief HPI of a problem-focused history
1-3 of the eight elements of the HPI
Problem-focused history has a brief HPI but no
ROS or PFSH
Brief HPI of an expanded problem-focused history
1-3 of the eight elements or 1-2 chronic problems
ROS of expanded problem-focused history
as it pertains to the presenting problem
Expanded problem-focused history has no PFSH but has
an ROS and a Brief HPI
How does the expanded problem-focused history differ from the problem-focused history?
With the expanded problem-focused history, information about the body system affected by the chief complaint is obtained, as in the HPI
A detailed history has an
Extended HPI, Extended ROS, and a Pertinent PFSH
Extended HPI of a detailed history
4 or more of the 8 elements
3 or more of the chronic conditions
Extended ROS of a detailed history
2-9 elements
Pertinent PFSH of a detailed history
1 of the 3 histories
How does the detailed history differ from the problem-focused or expanded problem-focused history?
The detailed history expands on the information gathered for the expanded problem focused history to include information about additional organ systems that may be related to the treatment of the current problem and to include pertinent personal and family information and family information
Extended HPI of a comprehensive history
4 or more of the 8 elements
3 or more chronic conditions
Complete ROS of a comprehensive history
10 or more elements
Complete PFSH of a comprehensive history
2 or 3 histories (2 for an establish patient and 3 for a new patient)
Why is a comprehensive history not taken in all cases?
A great deal of time and effort is required to take a comprehensive patient history
The extent of examinations performed and documented depends on (2)
- clinical judgement
2. nature of the presenting problem(s)
The examinations range from (2)
- limited exams of single body areas
2. general multi-system or complete single-organ system exams
Body areas include the following:
head, including the face; neck; chest, including breasts and axillae; abdomen; genitalia, groin, buttocks; back, including the spine; each extremity
Organ systems include
constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic(al); psychiatric; and hematological/lymphatic/immunologic
Problem-focused exam is limited to
1 body area or organ system
Expanded problem-focused exam is the
affected body area or organ system and other symptomatic or related organ system(s) with the requirements of 2 to 7 body areas and/organ systems
Detailed exam includes
an extended exam of the affected body area(s) or organ system(s) and other symptomatic or related organ systems with the requirements of 2 to 7 body areas and/or organ systems
Comprehensive exam includes
a general multisystem exam or a complete exam of a single organ system with requirements of 8 or more body areas and/or organ systems
1995 CMS Guidelines (Body areas/organ systems): problem focused
limited to the affected 1 BA or OS
1995 CMS Guidelines (Body areas/organ systems): expanded-problem focused
limited to the affect BA or OS and other related OS(s): 2-7 limited
1995 CMS Guidelines (Body areas/organ systems): detailed
extended of the affected BA(s) and other related OS(s): 2-7 extended
1995 CMS Guidelines (Body areas/organ systems): comprehensive
General multisystem (OSs only)
1997 CMS Guidelines (Bulleted elements): problem focused
fewer than 6 bullets
1997 CMS Guidelines (Bulleted elements): expanded-problem focused
6 or more bullets
1997 CMS Guidelines (Bulleted elements): detailed
12 or more bullets
1997 CMS Guidelines (Bulleted elements): comprehensive
18 or more bullets
1997 CMS Guidelines (multisystem exam): detailed examination
At least 2 bullets from any 6 BAs/OSs
At least 12 bullets from 2 or more BAs/OSs
1997 CMS Guidelines (multisystem exam): comprehensive examination
All bullets in at least 9 BAs/OSs and document at least 2 bullets from each side of the 9 BAs/OSs
Single-System Examinations
Ear, Nose Throat exam; Eye exam, Genitourinary exam, Hematologic/Lymphatic/Immunologic exam, Musculoskeletal exam, Neurological exam, Psychiatric exam, Respiratory exam, and Skin exam
CMS 1997 Guidelines (multisystem): problem focused
1 to 5 elements identified by a bullet
CMS 1997 Guidelines (multisystem exam): expanded problem focused
at least 6 elements divided by a bullet
CMS 1997 Guidelines (multisystem exam): detailed
at least 12 elements identified by a bullet
CMS 1997 Guidelines (multisystem exam): comprehensive
Perform all elements identified by a bullet; document every element in each box with a shaded border and at least 1 element in each box with an unshaded border
swelling of tissues, usually in the lower limbs, die to accumulation of fluids
peripheral edema
1995 Guidelines: Problem focused exam
1 affected organ system or body area
1995 Guidelines: Expanded problem-focused exam
limited exam of 2-7 organ systems and/or body areas
1995 Guidelines: Detailed exam
Extended exam of 2-7 organs systems and/or body areas
1995 Guidelines: Comprehensive exam
8 or more organ systems or body areas - a general multisystem exam
unaffected or asymptomatic organ system is listed as
“negative” or “normal”
Medical decision making includes
- how complex the physician’s decision is to determine the diagnosis and/or choose the plan to manage the situation
- the amount and/or complexity of data to review
- the risk of significant complications, morbidity, and/or mortality
problems that are improving or resolving…
take less decision making than diagnoses that are worsening or failing to change as expected
Treatments include
management options consisting of patient instructions, nursing instructions, therapies, and medications
For referrals, consultations requested, or advice sought, the notes should state…
the specifics about “who”
point system: self-limited, minor, or improving
1 pt. (max. 2 pts. per case)
a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance
self-limited or minor
point system: established patient; stable/improved
1 pt
point system: each established worsening problems
2 pts.
point system: a new problem with no additional work planned
3 pts.
point system: a new problem with additional workup planned
4 pts.
workup
the procedures done to arrive at a diagnosis, including history taking, laboratory tests, x-rays, and so on
diagnosis/management: minimal
1 pt or less
diagnosis/management: limited
2 pts
diagnosis/management: multiple
3 pts
diagnosis/management: extensive
4 pts or more
Amount and/or Complexity of Data to Review covers
the types of diagnostic testing ordered or reviewed
All tests and procedures should be _____, whether ordered, planned, scheduled, or performed at the time of service
documented
An entry in a chart note such as “WBC elevated” or “chest x-ray unremarkable” documents a review of a test but must include
the physician’s initials and date on the report
Statements including “old records reviewed” or “additional history obtained from family”…
do NOT document the physician’s review in the patient’s record
Risk of Significant Complications, Morbidity, and/or Mortality includes
risks associated with the CC, diagnostic procedure(s), and possible management options
Self-limited, minor problem runs
a definite and prescribed course, is transient in nature, and is not likely to alter health status permanently or has a positive prognosis with management and compliance
Level of Risk is based on the:
- Presenting Problem
- Diagnostic Procedures Order
- Management Options Selected
Presenting Problem is the ____ column
first
Diagnostic Procedures Ordered is the _____ column
second
Management Options Selected is the _____ column
third
The overall measure of risk is the
highest level circled
Steps for choosing the E/M Code
New or established patient?
Identify the place of service
Choose the code matching the level of service
(NP = 3 of 3, EP = 2 of 3)
Choosing the Correct E/M Level: new-patient
All 3 of the key components must meet or exceed the stated CPT requirements for the code
Choosing the Correct E/M Level: established-patient
2 of the 3 key components must meet or exceed the stated CPT requirements
