E&M coding

Question 1

PF (history)

Answer 1

problem focused documentation: patients with simple problems

Note chief complaint, and a brief HPI (1-3 items). No ROS or PMFSH

Question 2

EPF (history)

Answer 2

extended problem focused. Chief complaint, brief HPI, and ROS of one system.
No PMFSH

Question 3

DTL (hisotry)

Answer 3

detailed documentation.

chief complaint, extended HPI (4 items OR status of 3 chronic problems), 2-9 system under ROS, and 1 pertinent PMFSH

Question 4

COMP (history)

Answer 4

comprehensive.

chief complaint, extended HPI, >=10 systems under ROS, and complete PMFSH

Question 5

PF (physical exam)

Answer 5

1-5 elements from one or more organ systems

Question 6

EPF (physical)

Answer 6

> =6 elements from any organ system

Question 7

DTL (physical)

Answer 7

> =2 elements from 6 organ systems OR 12 elements from 2 or more organ systems

Question 8

COMP (physical)

Answer 8

2 elements from each of 9 organ systems

Question 9

Medical Decision-making coding

Answer 9

S: straightforward, minimal risk, e.g. insect bite
L: low risk, e.g. one stable chronic illness/ sprained ankle
M: moderate risk, e.g. one stable chronic illness with mild exacerbation
H: high risk, complex evaluation of an existing patient whose chronic condition worsens.

Question 10

what are the common levels of complexity for clinic visits

Answer 10

1-5