Lesson 4 E/M Codes Part 1 Flashcards
E/M codes are used for…
Every type of physician to report patients encounters for health related problems. They are considered cognitive codes because physicians must gather and analyze data and information regarding each patient to make a decision about the condition and determine how to manage it.
What do E/M codes represent?
The physicians evaluation of a patients condition and management of the patients care.
What 5 questions should a coder ask themselves when choosing an E/M code?
- Who is the patient?
- What is the place of service?
- What is the patients name?
- What type of service is being provided?
- What level of service is being provided?
A patient is considered “new” is they have not received any professional services from the physician within _____ of years.
3
POS
Place of Service
What are the 4 levels of service?
Problem focused
Expanded problem focused
Detailed
Comprehensive
Determining the level of service is based off of what factors?
History Examination Medical decision making Counseling Coordination of care Nature of presenting problem Time
What are considered the key components in selecting level of service?
History
Examination
Medical decision making.
Counseling, coordination of care, nature of presenting problem, and time are considered?
Contributory components.
How many key components must be considered when assigning codes for new patients?
All three
How many key components must be present for established patients?
Two of the three
What does a history of the patient include?
Chief complaint (CC)
History of present illness
Review of systems (ROS)
Past/family/social history (PFSH)
What is a Chief Complaint?
A concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patients own words.
What is an HPI, history of present illness?
Chronological description of the development of the patients present illness from the first sign and/or symptom or from the previous encounter to the present.
What are the two types of HPIs?
Brief and extended
A brief HPI includes documentation of _____________ HPI elements.
One to three
What is a Review of Systems?
An inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing of has experienced.
What are the three types of ROS?
Problem pertinent
Extended
Complete.
What is a problem pertinent ROS?
Inquires about the system directly related to the problem identified in the HPI.
What does a complete ROS inquire about?
The systems directly related to the problem(s) identified in the HPI and a limited number of additional systems for a total of 2-9 systems.
What does a complete ROS inquire about?
The systems directly related to the problem identified in the HPI plus all additional (minimum of 10) organ systems.
What are the two types of PFSH?
Pertinent and complete.
A complete PFSH requires a review of _________________ for services that by their nature include a comprehensive assessment or reassessment of the patient.
All three history areas
A rule of thumb regarding the number of PFSH elements is that generally an established patient will require two of the three PFSH elements, while a new patient will require documentation of all three to meet the requirements of a complete PFSH. (Not a question just a little fun fact)
No answer
You should probably read your notes on this chapter bc there are a lot of little tid bits.
Yup, tid bits.
