OMT Documenting & Coding Flashcards
What are CPT?
codes used for billing clinical encounters with patients
What are E&M codes?
used for patient evaluation & disease management
What is the significance of the Health Insurance Portability & Accountability Act of 1996?
required transition to EMRs in 15yr period
allowed electronic financial chart audits
“if it isn’t written, it didn’t happen”
What are evaluation and management codes based on?
the more physical & mental work performed by the physician, the higher the level of complexity code selected
What are the 3 key elements of E&M codes?
History
PE
Medical Decision Making
How are each 3 visit portions scored in terms of complexity?
History level requires 2 of 3 areas to meet or exceed its overall selected complexity
PE is scored by quantity of examinations
Decision Making requires 2 of 3 areas to meet or exceed its overall selected complexity
What is required in the history for coding?
CHIEF COMPLAINT (required for any billing)
HPI ROS PMH SH FH
What is considered a comprehensive HPI?
> 3 of sxs & symptoms with other items
What is considered a complete ROS?
10+
What is considered a complete past history?
1 element from PMH
1 element from FH
1 element from SH
How is the code for Objective/History met?
Hx
ROS
PMH
2 of 3 must meet or exceed
How is the PE scored?
Problem focused (1-5 elements)
Expanded problem focused (6+ elements)
Detailed (2 bullets each in 6 systems)
Comprehensive (2 of 9+ systems)
How many vital signs must you record?
need at least 3 vital signs
What is the Medicare rule for impressions under assessment of pt?
be as specific as possible (list sxs only when cause is unknown & if unclear the SD is cause of sx)
What are the 3 components of medical decision making?
number of dx & tx (quantity)
amount of medical data review (quantity)
complexity of dx & risk level
What determines the level of service?
RISK is the driving determinant for level of service (1 of 3 qualifying levels MUST be RISK)
What are the points for number of dx & tx based on?
self limited (1) established dx (1) establish dx that is worsening (2) new problem w/ no further eval (3) new problem w/ further eval (4)
What are the points for amount of data reviewed?
reviewed or ordered lab (1)
discussed result w/ pt (1)
DECISION to review old records/past visits (1)
independent review of items (2)
What are minimal and low risk categories?
minimal risk (level 2) w/ 1 self-limited or minor (cold, insect bite)
low risk (level 3) w/ 1 stable chronic, 1 acute uncomplicated (controlled HTN & return for RX refill)
What is moderate risk (level 4)?
chronic illness w/ mild exacerbation or progression
medication side effects
2 or more stable
acute w/ systemic sx
complicated inury
undiagnosed new problem w/ uncertain prognosis
What is high risk?
illness or event that poses eminent threat to life or body function
1 or more chronic illness w/ severe exacerbation or progression or side effects
diagnostics
What does SD dx documentation require?
requires 1 of 4 of TART (tenderness, asymmetry, restricted ROM, tissue texture abnormalities)
Where is SD documented?
OBJECTIVE (T4 F SR RR)
What is required in documentation of plan?
consent decision to perform OMT disposition post procedure response to tx post procedure care
