Intro Flashcards
family medicine
-oldest medical specialty
-Most diverse - covers peds to geriatric
-Provide dx, therapeutic, and preventive care across pts lifespan
-Routine checkups
-Health risk assessments
-Immunizations
-Screening tests
-Healthy lifestyle counseling
-Tx of common chronic conditions
-minor surgical procedures
internal med vs family med
-INTERNAL MED
-in depth training for adult medicine -> EM, critical care, subspecialties
-most training in inpt -> 3 yrs
-only perform minor procedures, very infrequent
-mostly inpt focused on chronic adult ds
-FAMILY MED
-broader range of medical subspecialties -> peds, obgyn, other
-some training inpt but majority outpt
-will perform what is needed if in rural setting
-major focus on preventative care
inpatient
-tx administered to pt whose condition requires tx in hospital and pt is formally admitted to facility by doctor
outpt
-consultation, procedure, tx, service without overnight stay
-MC- routine PE by PCP
-preventative services - colonoscopy, dx imaging/mammo, chemo/radiation tx
-same day procedures:
-hip and knee replacement
-dental surgery
-gastric bypass
-breast augmentation
benefits of outpatient
-recover from tx or surgical procedure in home
-improve pt experience
-decrease risk of hospital acquired conditions and healthcare associated infection
observation status
-pt has condition that provider wants to monitor to see if you require inpatient admission.
-Observation status is outpatient status, but it can also last for multiple days, depending on the circumstances (ie, the fact that you’re in the hospital overnight doesn’t necessarily mean you’ve been assigned inpatient status).
why does admission status matter
-important forOriginal Medicare beneficiaries, because:
-Medicare Part A pays for inpatient.(with a single deductible for the 1st 60 days of care in a benefit period.
Whereas,
-Medicare B pays for outpatient care, with a deductible pays coinsurance based on services provided
ICD-10
-international classification of ds
-describes pts signs, sx, condition, complaint, problem
-justify pts medical necessity
-ex. 4 procedures = 4 different ICD to prove medical necessity
-these are in the assessment
CPT codes
-current procedural terminology
-describes medical, surgical, and dx services
-communicates uniform information about medical services and procedures among physicians, coders, pts, accreditation, organizations, and payers for administrative, financial, and analytical purposes
-time includes prework and writing the note
acuity of pt
-based on how many dx or management that youre writing ab in ur note
-if you dont write out ruling stuff out and all the things you did -> you lower acuity
-elaborate note = higher acuity
-History Component
-CC- required & cannot be inferred
-HPI-cannot be documented by staff
-ROS-& PFSH can be documented by staff
-PFSH (past, family, social history)
-Physical Examination
-Number of organ systems examined
-Medical Decision Making: Assessment and Plan
-# diagnoses or management options
-Amount of data/complexity
-Risk level to the patient
ethics and coding
-Actual Service Performed
-Coding for coverage- Not picking the best code for the procedure , just something that is covered
-Upcoding
-Double billing- when the PA and doctor bill for the same thing
-Unbundling- billing for something that included in the bundle you billed for (ex. you bill for ICU and then also bill for IV -> That included)
-something that can be justified is central line or chest tube
-Separating coding- billing for excisional biopsy and then plastics closure -> if you bill for excisional bx obviously you are going to close it
