E/M Section Flashcards
what are the 3 factors of E/M codes
- place of service
- type of service
- patient status
- place of service includes
physician’s office, hospital, emergency department, nursing home, and so on
- types of service includes
reason the service is requested or performed,
consultation, admission, newborn care, office visit
consultation
writtten or verbal request from one provider/physician to another
admission
attention to an acute illness or injury that results in admission to a hospital
newborn care
evaluation and determination oc care management
office visit
face-to-face encounter b/t a physician and a patient to allow primary management
- patient status includes
new, established, outpatient, inpatient
new pt
one who has not received professional services in the past 3 years
established
one who has received professional services from a physician in the sam group within the past 3 years
outpatient
one who has not been formally admitted to a health care facility or a pt admitted for observation
inpatient
one who has been formally admitted to a health care facility
medical record documentation has many uses which are
evaluation of the pts treatment, communications regarding the pts health care, reimbursement claims, review of the use of the health care facility, research/education, and legal documentation
7 organizations developed minimum documentation guidelines are
- american health information management association
- american medical peer review association
- BCBS association
- american hospital association
- managed care and review association
- american medical association
- health insurance association of america
guidelines are as follows
- medical record should be complete and legible
- doc. should include date, reason for encounter, h&p, review of ancillary services, assessment, and plan of care, drs. signature and date
- past and present dx
- reasons for results of x-rays, lab, and other ancillary service
- relevant risk factors-identifed
- pts progress and response to treatment, change in treatment or dx, and any noncompliance should be doc.
- written plan of treatment
- report the intensity of the pt evaluation and/or the treatment including thought processess and complexity of the medical decision making.
- entries should be dated and authenticated by provider or provider extender
- cpt and icd-10 codes reported on the insurance claim or billing statement should reflect the documentation in the medical record
levels of e/m service are (2)
key components and contributory factors
key components
history, exam and medical decision making complexity
contributory factors
counseling, coordination of care, nature of presenting problem, and time
(99214) office or other out pt visit for e/m of an established pt requires at least 2 of 3 key components are
- detailed hx
- detailed exam
- medical decision making of moderate complexity
history
subjective information the pt tells the physician based on the 4 elements of a hx
4 elements of a hx are
chief complaint (cc)
history of present illness (hpi)
review of systems (ros)
past, family, and/or social hx (pfsh)
T/F some history elements may be documented by ancillary staff or the patient
F - ancillary staff are allowed to document some of the hx, such as cc and pfsh, but the physician must authenticate the entries
(CC) chief complaint
concise statement describing the symptom, problem, condition, dx, physician-recommended return, or other factor that is is the reason for the encounter, stated in the pts words
(HPI) history of present illness
chronological description of the development of the pts present illness from the first sign/symptom or from the previous encounter to the present
(HPI) elements may include what (8)
location, quality, severity, duration, timing (am, afternoon, night,etc.), context (under what circumstances does it occur), modifying factors (circumstances make it better or worse), associated signs and symptoms
(ROS) review of systems
inventory of body systems obtained through a series of questions seeking to identify signs/symptoms that pt may be experiencing or has experienced
History levels (4)
problem focused, expanded problem focused, detailed, comprehensive
problem focused
physician focuses on the chief complaint and a brief hx of the present problem of a pt, a brief hx includes 1-3 of the 8 elements
expanded problem focused
focuses on the chief complaint and a brief hx of the present problem and also performs a problem pertinent review of systems, (does not have to include the past, family, or social hx), hx would center around specific questions regarding the system involved in the presenting problem or CC
detailed
focuses on a cc, obtains an extended hx of the present problem (4 or more of the 8 elements) an extended review of systems and a pertinent PFSH
comprehensive
most complex of the hx types, doc. CC, obtains an extended hx of the present prob. does a complete review of systems, and obtains a complete PFSH
PFSH means
past, family, and social history
ROS means
review of systems
HPI means
history of present illness
CC means
cheif complaint
8 elements of HPI-history of personal illness
- location (site on body)
- quality (characteristic, throbbing, sharp)
- severity (how intense)
- duration (how long)
- timing ( when it occurs)
- context (what circumstances does it occur)
- modifying factors (what makes it better or worse)
- associated signs and symptoms (what else is happening when it occurs)
elements required for each level of history - problem focused
HPI-brief 1-3
ROS-none
PFSH-none
elements required for each level of history - expanded problem focused
HPI-brief 1-3
ROS-problem-pertinent 1
PFSH-none
elements required for each level of history - detailed
HPI-extended 4+
ROS-extended 2-9
PFSH-pertinent 1
elements required for each level of history -comprehensive
HPI-extended 4+
ROS-complete 10+
PFSH-complete 2-3
history elements - CC
reason for the encounter in the pts words
history elements - HPI (history of present illness)(8)
location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms
history elements - ROS(review of systems)(14)
constitutional symptoms, ophthalmologic, otolaryngologic, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic
history elements - PFSH(past, family, and/or social history)(3)
- past major illnesses, operations, injuries, and treatments
- family medical history for heredity and risk
- social activities, both past and current
constitutional symptoms includes
fever, weight loss, etc
integumentary includes
skin and/or breast
-examination levels(4)
- problem focused
- expanded problem focused
- detailed
- comprehensive
-examination level - problem focused
limited to the affected body area or organ system identified by the cc
-examination level - expanded problem focused
limited to the affected body area or organ system and other symptomatic or related boy area(s)/organ system(s)
-examination level - detailed
extended-made of the affected body area(s) and other symptomatic or related organ system(s)
-examination level - comprehensive
most extensive, encompasses a general multi-system examination and should include findings about 8 or more of the 12 organ systems
-examination elements - constitutional (OS)(organ system)(8)
- BP sitting
- BP lying
- pulse
- respirations
- temperature
- height
- weight
- general appearance
-examination elements - body area (BA)(body area)(7)
- head-including face
- neck
- chest-including breasts and axillae
- abdomen
- genitalia, groin, buttocks
- back
- each extremity
-examination elements - organ system (OS)(organ system)(12)
- ophthalmologic-eyes
- otolaryngologic-ears, nose, mouth, throat
- cardiovascular
- respiratory
- gastrointestinal
- genitourinary
- musculoskeletal
- integumentary-skin
- neurologic
- psychiatric
- hematologic/lymphatic/immunologic
elements required for each level of examination - problem focused
- examination-limited to affected BA or OS
- # of OS/BA - 1
elements required for each level of examination - expanded problem focused
- examination-limited to affected BA or OS and other related OS(s)
- # of OS/BA - 2-7 limited
elements required for each level of examination - detailed
- examination-extended of affected BA(s) and other related OS(s)
- # of OS/BA - 2-7 extended
elements required for each level of examination - comprehensive
- examination-general multi-system (OSs only)
- # of OS/BA - 8+
Newborn care services
99460-99465 - reports services t normal newborns
99463
newborn assessment and discharge from a hospital or birthing room on the same date
99460
hospital or birthing room deliveries
99461
other than a hospital or birthing center
99462
initial services are reported on a per day basis, subsequent services are reported with 99462
99238, 99239
physician provides a discharge service to a newborn discharged subsequent to the admission date, ou would choose a code from the hospital inpatient services subsection, hospital discharge services subheading
deliver/birthing room attendnce and resuscitation services
99464, 99465 - reports the attendance of a physician, at the request of the delivering physician, to provide the initial stabilization of a newborn or for the resuscitation/ventilation of the newborn
inpatient neonatal intensive care and pediatric neonatal critical care services
99466-99486
99466, 99467
report face to face services provided to a pediatric pt 24 months or younger
chronic care management services
99490-99491 - requires the pt to have two or more chronic conditions that are expected to last at least 12 months or result in death
complex chronic care management services
99487, 99489 - report complex chronic care management services provided during a month
other evaluation and management services
99499 - last subsection in the E/M section, unlisted code that is used to indicate that there is no other code that accurately represents the services provided to the pt.
