OMT Documenting & Coding

Question 1

What are CPT?

Answer 1

codes used for billing clinical encounters with patients

Question 2

What are E&M codes?

Answer 2

used for patient evaluation & disease management

Question 3

What is the significance of the Health Insurance Portability & Accountability Act of 1996?

Answer 3

required transition to EMRs in 15yr period

allowed electronic financial chart audits

“if it isn’t written, it didn’t happen”

Question 4

What are evaluation and management codes based on?

Answer 4

the more physical & mental work performed by the physician, the higher the level of complexity code selected

Question 5

What are the 3 key elements of E&M codes?

Answer 5

History
PE
Medical Decision Making

Question 6

How are each 3 visit portions scored in terms of complexity?

Answer 6

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

Question 7

What is required in the history for coding?

Answer 7

CHIEF COMPLAINT (required for any billing)

HPI
ROS
PMH
SH
FH

Question 8

What is considered a comprehensive HPI?

Answer 8

> 3 of sxs & symptoms with other items

Question 9

What is considered a complete ROS?

Answer 9

10+

Question 10

What is considered a complete past history?

Answer 10

1 element from PMH
1 element from FH
1 element from SH

Question 11

How is the code for Objective/History met?

Answer 11

Hx
ROS
PMH

2 of 3 must meet or exceed

Question 12

How is the PE scored?

Answer 12

Problem focused (1-5 elements)
Expanded problem focused (6+ elements)
Detailed (2 bullets each in 6 systems)
Comprehensive (2 of 9+ systems)

Question 13

How many vital signs must you record?

Answer 13

need at least 3 vital signs

Question 14

What is the Medicare rule for impressions under assessment of pt?

Answer 14

be as specific as possible (list sxs only when cause is unknown & if unclear the SD is cause of sx)

Question 15

What are the 3 components of medical decision making?

Answer 15

number of dx & tx (quantity)
amount of medical data review (quantity)
complexity of dx & risk level

Question 16

What determines the level of service?

Answer 16

RISK is the driving determinant for level of service (1 of 3 qualifying levels MUST be RISK)

Question 17

What are the points for number of dx & tx based on?

Answer 17

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)

Question 18

What are the points for amount of data reviewed?

Answer 18

reviewed or ordered lab (1)
discussed result w/ pt (1)
DECISION to review old records/past visits (1)
independent review of items (2)

Question 19

What are minimal and low risk categories?

Answer 19

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)

Question 20

What is moderate risk (level 4)?

Answer 20

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

Question 21

What is high risk?

Answer 21

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

Question 22

What does SD dx documentation require?

Answer 22

requires 1 of 4 of TART (tenderness, asymmetry, restricted ROM, tissue texture abnormalities)

Question 23

Where is SD documented?

Answer 23

OBJECTIVE (T4 F SR RR)

Question 24

What is required in documentation of plan?

Answer 24

consent
decision to perform OMT
disposition post procedure
response to tx
post procedure care

Question 25

How does billing of OMT in an office visit include?

Answer 25

procedure (OMT) & the E&M visit may both be billed w/ same diagnosis code & during the same encounter, if the decision to perform the procedure was made @ the time of the encounter

Question 26

What are the 4 main parts of a produce note?

Answer 26

consent (benefits, risk, side effects, costs)

procedure description (body regions, techniques)

disposition (response to tx, any complications)

follow up plan (post procedure care)

Question 27

What is important about the procedure description?

Answer 27

may be fairly nonspecific

may be very specific

Question 28

What are important recommendations about E&M?

Answer 28

qualify the chief complaint

qualify the diagnosis