Lesson 4 E/M Codes Part 1

Question 0

E/M codes are used for…

Answer 0

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.

Question 1

What do E/M codes represent?

Answer 1

The physicians evaluation of a patients condition and management of the patients care.

Question 2

What 5 questions should a coder ask themselves when choosing an E/M code?

Answer 2

1. Who is the patient?
2. What is the place of service?
3. What is the patients name?
4. What type of service is being provided?
5. What level of service is being provided?

Question 3

A patient is considered “new” is they have not received any professional services from the physician within _____ of years.

Answer 3

3

Question 4

POS

Answer 4

Place of Service

Question 5

What are the 4 levels of service?

Answer 5

Problem focused
Expanded problem focused
Detailed
Comprehensive

Question 6

Determining the level of service is based off of what factors?

Answer 6

History
Examination
Medical decision making
Counseling
Coordination of care
Nature of presenting problem
Time

Question 7

What are considered the key components in selecting level of service?

Answer 7

History
Examination
Medical decision making.

Question 8

Counseling, coordination of care, nature of presenting problem, and time are considered?

Answer 8

Contributory components.

Question 9

How many key components must be considered when assigning codes for new patients?

Answer 9

All three

Question 10

How many key components must be present for established patients?

Answer 10

Two of the three

Question 11

What does a history of the patient include?

Answer 11

Chief complaint (CC)
History of present illness
Review of systems (ROS)
Past/family/social history (PFSH)

Question 12

What is a Chief Complaint?

Answer 12

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.

Question 13

What is an HPI, history of present illness?

Answer 13

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.

Question 14

What are the two types of HPIs?

Answer 14

Brief and extended

Question 15

A brief HPI includes documentation of _____________ HPI elements.

Answer 15

One to three

Question 16

What is a Review of Systems?

Answer 16

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.

Question 17

What are the three types of ROS?

Answer 17

Problem pertinent
Extended
Complete.

Question 18

What is a problem pertinent ROS?

Answer 18

Inquires about the system directly related to the problem identified in the HPI.

Question 19

What does a complete ROS inquire about?

Answer 19

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.

Question 20

What does a complete ROS inquire about?

Answer 20

The systems directly related to the problem identified in the HPI plus all additional (minimum of 10) organ systems.

Question 21

What are the two types of PFSH?

Answer 21

Pertinent and complete.

Question 22

A complete PFSH requires a review of _________________ for services that by their nature include a comprehensive assessment or reassessment of the patient.

Answer 22

All three history areas

Question 23

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)

Answer 23

No answer

Question 24

You should probably read your notes on this chapter bc there are a lot of little tid bits.

Answer 24

Yup, tid bits.