E/M Flashcards
Key Components
- History
- Exam
- MDM
Contributory Factors
1 counseling
2 coordination of care
3 nature of presenting problem
4 time
Elements of a History
1 chief complaint
2 HPI
3 ROS
4 PFSH
How many elements of HPI
8
Elements of HPI
1 location
2 severity
3 quality
4 duration
5 timing
6 context
7 modifying factors
8 associated signs and symptoms
How many elements of ROS
14
Elements of ROS
1 constitutional
2 eyes
3 ears, nose, mouth, throat
4 cardiovascular
5 respiratory
6 integumentary
7 musculoskeletal
8 neurology
9 psych
10 hemotalogic/lymphatic
11 allergic/immuno
12 endocrine
13 gastrointestinal
14 genitourinary
PFSH
Past Family and Social History
Nursing Services formerly known as
Skilled Nursing (SNF)
Intermediate Care (ICF)
Long-Term Care (LTCF)
Preventative care based on what
age
If significant problem encountered during preventative services add what
Modifier -25
Elements of MDM
- Number of diagnoses and manage management options
- Amount or complexity of date
- Risk of complications or death
Levels of preventative care based on
Age
Number of organ systems
12
12 Organ Systems
Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitounrinary
Musculoskeletal
Integamentary
Neuro
Psych
Hem/Lymph/Immuno
Number of Body Areas
10
Body Areas
Head
Neck
Chest
Abdomen
Genetalia, groin, buttocks
Back
Each extremity (4)
First consult is a consult code, second visit what kind of code
Subsequent hospital code
3rd party payer requests consult add what
Modifier -32
Exam levels
Problem Focused
Expanded Problem Focuses
Detailed
Comprehensive
MDM Levels
Straighforward
Low
Moderate
High
History Levels
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
3 Factors of E/M Codes
Place of Service
Type of Service
Status of Patient
Patient Status
Inpatient
Outpatient
New Patient
Established Patient
