Documenting and Coding Flashcards
What is the name of the system of codes used for billing clinical encounters with patients?
Common Procedure Terminology (CPT)
What codes are used for patient evaluation and disease management?
E and M codes
-these vary based on location (hospital v. clinic)
Which Act required a transition to electronic medical records and allowed electronic financial chart audits?
HIPAA of 1996
True or False: in selection of E and M codes, the more physical and mental work performed by the physician, the higher the level of complexity code selected
True; it’s based on the complexity of: history, physical exam, and medical decision making
Which aspect of a physician visit does Medicare place the highest priority on?
Medical Decision Making
True or False: a Chief Complaint (CC) in the History/Subjective section is required for any billing
True
For components of the HPI (location, quality, severity, duration, timing, etc.), what levels dictate the complexity of the History for coding purposes?
1-3 = brief
> 3 = extended
>3 with other elements = comprehensive
For completing a ROS (CV, ENT, Eyes, GI, GU, MSK, Neuro, Psych, Resp, etc.), what levels dictate the complexity for coding purposes?
1 = problem pertinent 2-9 = extended 10+ = complete
For completing the Past Histories section of the HPI (PMH, Family Hx, Social Hx), what levels dictate the complexity for coding purposes?
1 = pertinent 2 = complete 3 = complete (new pt., hospital, or consult > level 3)
For the scoring of the physical exam complexity, what are the levels?
Problem-Focused = 1-5 elements
Expanded Problem-Focused = 6+ elements
Detailed = 2 bullets in each of 6 systems (12+ bullets)
Comprehensive = 2 bullets in 9 systems (complete PE)
From what source do the medical diagnoses come, and who maintains/publishes it?
ICD-10 by the WHO
What is a good “rule” to keep in mind in regards to Medicare?
- Be as specific as possible.
- Only list Sx when the cause is unknown.
-You can list symptoms in addition to a SD if it’s unclear whether or not the SD is their cause, and no other diagnosis is known.
For a somatic dysfunction, according to the ICD-10, how should you list them?
-by body region only, NOT individual findings
What are the levels in Medical Decision Making?
Straight-Forward
Low Complexity
Moderate Complexity
High Complexity
What three components go into determining the complexity level for Medical Decision Making and which component is the driving determinant for the level of service?
- number of diagnoses and treatments
- amount of medical data reviewed
- complexity of diagnosis and its RISK level
-Risk determines level of service; MUST be included
What are the levels of diagnosis and risk?
self-limited = 1 point
established diagnosis = 1 point (if stable or improved)
established diagnosis = 2 points (if worsening)
new problem w/o further eval = 3 points
new problem w/ further eval = 4 points
What are the levels of medical data review?
review or order lab, x-ray, etc. = 1 point
discuss results w/ pt. = 1 point
decision to review old records or visits = 1 point
independent review of UA, ECG, etc. = 2 points
What are examples of the minimal risk level?
–one self-limited minor condition (ex: cold, insect bite)
- mgmt may require some testing (CXR, UA)
- mgmt w/ rest, OTC’s, bandages
What are examples of the low risk level?
–2+ self-limited, 1 stable chronic, or 1 acute uncomplicated condition (ex: controlled HTN)
-mgmt may include OTC, minor surgery, PT, IV saline
What are examples of the moderate risk level?
- chronic illness w/ exacerbation, or 2+ stable condition
- medication side effects
- acute condition w/ systemic symptoms
- complicated injury (e.g. head injury w/ concussion)
- undiagnosed new problem w/ uncertain prognosis
What are examples of the high risk level?
-illness/event that poses eminent threat to life
(MI, PE, resp distress, change in neuro status)
-1+ chronic illness w/severe exacerbation
Of the three visit portions (History, Physical Exam, and Medical Decision Making), how many must score at or above a certain complexity level (1-5) for that complexity level to be assigned to the visit?
2 out of the 3
For diagnosis of a somatic dysfunction, how many of the TART findings (tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities) are required?
only 1
How do you document the physical findings of a somatic dysfunction?
In the objective section, describing the individual elements:
- right ASIS tender, right ASIS superior, etc.
- positive Adson’s Maneuver on the right
