Chapter 8 Short Notes Flashcards
Assignment codes from the E/M section is determined by three factors
- place of service
- type of service
- patient statue
assignment code that explains the setting
place of service
Office visits may include…
routine physical examinations or problem-focused examinations of limited scope
a request to obtain an opinion or advice about a diagnosis or management option from another physician or other appropriate source
consultation
attention to an acute illness or injury that results in admission to a hospital
admission
face-to-face encounter between a physician and a patient that allows for primary management of the patient’s health
office visit
patient who has not received professional health service in the past three years
new patient
any patient not classified as new
established patient
patients that have not been formally admitted to a health care facility
outpatient
patients who have been formally admitted to a healthcare facility including a hospital or nursing facility
inpaitent
foundation for the level of service
nature of the presenting problem
main consideration when determining reimbursement for E/M services and procedures
level of service
key components in E/M levels are…
history, examination, and medical decision making
contributory factors in E/M levels are…
counseling, coordination of care, nature of the presenting complaint, and time
the nature of the presenting complaint will…
- 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 are…
CC, HPI, ROS, and PFSH
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
HPI
Level of History: brief
1 to 3 elements are in the notes
Level of History: extended
4 or more elements are in the notes
thorough inventory of anatomical body systems obtained through a series of questions designed to identify signs and symptoms the patient may be experiencing
ROS
Problem-pertinent ROS includes
the patient’s responses for the symptoms related only to the problem
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 systems must be reviewed
patients illnesses, operations, hospitalizations, injuries, allergies, current medications, immunizations, and dietary status
past history
set of questions relating to past and current activities common for the patient’s age
social 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
family history
new patients office visits include
all 3 areas of PFSH
established office visits include
2 of the 3 areas of PFSH
initial visits require
1 of the 3 areas of PFSH
