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1605 CPT > Chpt 3 > Flashcards

Chpt 3 Flashcards

1
Q

Evaluation and Management

A

1st section of CPT
Billable services
1st evaluation by healthcare provider
Then implement management plan and record in the medical record

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2
Q

Original guidelines for E/M

A

AMA & CMS
1995 & 1997
Labor intensive to document all the components needed for code justification
Be aware for audits of retrospective period
Internet links for both at CMS.gov

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3
Q

Revised guidelines

A

January 1, 2021, AMA -streamlined 99202-99215
January 1, 2023 for other CPT codes

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4
Q

E/M code questions

A

Is the patient new or established?
Where was the service provided?
What was the level of the service rendered?

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5
Q

New patient points

A

Same specialty or subspecialty
Same group practice
Three years

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6
Q

Place of Service code

A

Different than E/M code
Box 24B of CMS-1500
Codes maintained by CMS

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7
Q

Medical decision making

A

The number and complexity of problems addressed at the encounter
The amount and/or complexity of data reviewed and analyzed
The risk of complications and/or morbidity or mortality of patient management

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8
Q

Risks of complications level

A

Minimal, low, moderate, high
Based on the risks associated with presenting problems, the diagnostic procedures and possible management problems

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9
Q

Determine the amount and complexity of the data reviewed

A

More tests and procedures reviewed by the provider, the higher the level of this element
The review of of a report can be documented with a provider note or the provider can initial and date the report
If the provider personally reviews the specimen or image they ordered, the complexity of the reviewed data increases
When documenting the complexity of data reviewed, providers should clearly document the information in order to justify the types of data reviewed
The risk of complications and/or mortality or morbidity of patient management

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10
Q

Select type of risk

A

Comorbidities and underlying diseases increase the complexity of risk
Surgical and invasive procedures performed during the encounter increase risk
Problems that pose a threat to life or bodily function increase risk
The more complex the diagnostic tests ordered, the greater the risk
The more complex the management options ordered are, the greater the risk

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11
Q

4 types of medical decision making regardless of location

A

Straightforward, low, moderate , high

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12
Q

99211

A

Reported for an office or outpatient visit for an established patient that does not require the presence of a physician or other healthcare provider

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13
Q

MDM

A

Justification of MDM is provider’s documentation

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14
Q

MDM Tables

A

List the specific elements that are needed for each type of MDM.
2 of 3 elements must be met or exceeded to qualify for a specific level of MDM

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15
Q

MDM decided on time

A

Requires a face-to-face encounter between the provider and the physician

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16
Q

ROS

A

Review of systems
Obtained by querying the patient

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17
Q

PFSH

A

Past, family and/or social history
Past: any past medical information that may affect the decision-making process

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18
Q

Office POS

A

11

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19
Q

School POS

A

3

20
Q

Home POS

A

12

21
Q

Assisted living facility

A

13

22
Q

Urgent care facility POS

A

20

23
Q

Inpatient hospital POS

A

21

24
Q

Skilled nursing facility

A

31

25
Q

Emergency room-hospital POS

A

23

26
Q

Consultation visits require a written report

A
27
Q

Observation status

A

Not required to be located in a designated area
The patient is classified as ‘observation status’

28
Q

Encounter at hospital spans 2 calendar dates

A

It is a single service reported on one date

29
Q

Seen in another site of service, then admitted to hospital

A

The not hospital visit may be coded, use modifier 25
Other site can include nursing facility or ED

30
Q

Consultations performed on the same day in relation to an inpatient admission

A

Use subsequent hospital codes

31
Q

Prolonged service visits in the hospital/observation

A

99418

32
Q

Admit and discharge on one day

A

Requires a minimum of two encounters

33
Q

One encounter of the admit and discharge

A

Select code from the hospital inpatient/ observation initial visit codes

34
Q

Discharge codes

A

99238-99239
Used for physician/QHP responsible for discharging services based on duration of time spent discharging the patient

35
Q

Physician not responsible for discharge

A

Use subsequent hospital codes
Hospital discharge when the patient has stayed overnight
99238-99239
For same day discharge use 99234-36

36
Q

Provider responsible for discharging the patient may use the discharge code, no one else

A
37
Q

Appropriate source for consultation

A

Physician, QHP, non-clinical social worker, educator, lawyer, insurance company

38
Q

Mandated consultation

A

Modifier 32

39
Q

3Rs
Consultation

A

Appropriate source
Recommendations
Report back to requester

40
Q

Even as an initial consultation

A

Must be reported as subsequent visit if the consultant saw him prior to admission

41
Q

Office consultation and hospital consultation

A

Code office consultation then hospital consultation as subsequent visit

42
Q

All consultations are initial

A
43
Q

MDM

A

Diagnosis list
Procedure list

44
Q

99252-99255

A

May be reported only once per consultant per admission of a patient who is in hospital inpatient or observation status

45
Q

ED Services

A

Hospital based, open 24 hours per day
If critical care on same day as ED visit, code only CC
If OBS status, admit and discharge on the same date, nursing facilities do not code ED
Code separately reported E/M services
Patients seen in the ED for the convenience of another physician/QHP code as office

46
Q

E/M

A

History/exam
Location of the visit
Type of visit: new/established
Total time
MDM
E/M tables to select the code
Apply all guidelines

47
Q

ED guidelines continued

A

Site of service might not solely determine the appropriate codes to report
Reporting additional services or procedures with ED services are permitted, use the appropriate modifiers: 54, 55, 56, 59, etc

1605 CPT (5 decks)

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