E&M Coding Flashcards
What category of E&M code would be needed for office or other outpatient services; these are codes used in ambulatory primary care and most other outpatient settings?
-Outpatient
_____ Patient Visit (99201 – 99205): patient has not seen you or another provider in your group in 3 years
New
_______ patient Visit (99211 – 99215): Patient has received professional services from you or someone in your group in the past 3 years
Established
This category of E&M coding is used for services provided to patients on observation status in a hospital. (99217 – 99220)
Hospital Observation Services
This category of E&M coding is used for services provided to patients while admitted to a hospital.
Hospital Inpatient services: Types: -Initial Hospital Care -Subsequent Care discharge care -Admit & disch same day
_____ Hospital Care (99221 – 99223): first hospital inpatient encounter with the patient by the admitting physician when ____ included in the global surgical package; also known as the _________ note or H&P.
- Initial
- NOT
- Admission
________ Care (99231 – 99233): follow up or daily visits when not included in the global surgical package
-Subsequent
This category of E&M coding is used for evaluation and management services provided in an emergency department (99281 – 99285).
Emergency Services
-No distinction is made between new and established patients
This category of E&M coding is used for provider visits to patients admitted in skilled nursing facilities.
Nursing home
- initial assessment 99301 – 99303
- subsequent 99311 – 99313
- discharge 99315 – 99316
This category of E&M coding is used for provider visits to patients living in custodial care settings.
Rest Home
- new patient 99321 – 99323
- established patient 99331 – 99333
This category of E&M coding is used for provider visits to patients’ homes.
Home Services
- new patient 99341 – 99345
- established patient 99347 - 99350
Name some other categories of services that E&M coding recognizes?
include critical care (adult, pediatric, and neonatal), case management services, care plan oversight, newborn care, and special evaluation and management services.
What category is the most important to focus on for out purposes?
Category 1 - Outpatient
In the 5 digit E&M code, what does the 4th digit tell you?
Category (Outpatient, Inpatient, ER)
What does the 5th and final digit of an E&M code tell you?
Determines the Level of Service provided
To determine the level of service, the provider must consider what factors?
The primary factors of history, exam, and medical decision making.
History and physical exam are rated using 4 descriptors, indicating the extent of evaluation done. What are they?
1) Problem focused (PF) - Least complex
2) Expanded problem focused (EPF)
3) Detailed (D)
4) Comprehensive (C) - Most complex
What makes up a Problem Focused History?
-CC & Brief HPI (1 to 3 elements)
What makes a History Expanded Problem Focused (EPF)?
- CC, Brief HPI
- problem-pertinent ROS: pertinent positives and negatives regarding associated symptoms in affected organ system
What makes a History Detailed?
- CC, Extended HPI (4 or more elements)
- Extended ROS (2 to 9 systems)
- Pertinent PMH, FH, or SH (1 of 3)
What makes the History Comprehensive?
- CC, Extended HPI
- complete ROS (10 systems)
- PMH, FH, SH (For NP: all 3 & For EP: 2 of 3)
A ______ ______ exam is defined as “a limited examination of the affected body area or organ system.”
Problem Focused
-Examine only affected body area or organ system; Asthma example: Lungs
An ________ ________ focused exam is defined as “a limited examination of the affected body area or organ system and other symptomatic or related organ systems.”
Expanded Problem Focused
-Asthma: Lungs + ENT or Heart
A ________ exam is defined as “an extended examination of the affected body area(s) and other symptomatic or related organ system(s).”
Detailed
- Extended exam of affected body area (lungs) and related organ systems
- Exam of lungs, ENT, cardiovascular, and extremities for cyanosis.
A _____________ exam is defined as “a general multi-system examination or a complete examination of a single organ system.”
Comprehensive
-Complete Multi-system exam
What are the 3 elements considered in determining the complexity of medical decision-making?
(2 out of 3 must be met or exceeded before a level is chosen: Straight forward, Low, Mod. High complexity)
1) Number of diagnoses and management options to be considered
2) Amount and complexity of data reviewed
- Labs
- Prior records
- Consultant reports
3) Risk level: complications, morbidity, mortality
The level of complexity of decision-making in a specific encounter is not determined by the __________ a patient carries. Comorbidities and __________ diseases are not considered in selecting a level of E&M services unless their presence significantly increases the _________ of the medical decision-making.
- Diagnosis
- Underlying diseases
- Complexity
(i. e., if a patient presenting w/fever & cough also had coexisting diabetes and COPD, that would affect the complexity b/c it will affect how you treat!)
Time is a ________ factor in determination of E&M codes. It is only used when counseling and/or coordination of care occupies more than ___% of the encounter (face-to-face time in the office setting).
- Secondary
- 50%
What’s the term for coding for a lower level than the service they provide?
Undercoding
-Fraud
Health maintenance visits, or “general check-ups” for healthy people, fall under the ___________ Medicine codes.
-Preventative
If only a procedure is done, no ________ and _________ code is charged.
Evaluation & Management
When more than one service is provided by the same clinician on the same day, _______ must be used.
Modifiers
-Procedure and E&M combo visits
This is the most common modifier in primary care where significant, separately identifiable evaluation and management service by the same provider on the same day of the procedure or other service.
Modifier 25
-i.e., Preventative “well visit” that presented with an abnormal mole and biopsy was taken same day!
