OMT Documenting & Coding Flashcards

1
Q

What are CPT?

A

codes used for billing clinical encounters with patients

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2
Q

What are E&M codes?

A

used for patient evaluation & disease management

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3
Q

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

A

required transition to EMRs in 15yr period

allowed electronic financial chart audits

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

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4
Q

What are evaluation and management codes based on?

A

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

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5
Q

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

A

History
PE
Medical Decision Making

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6
Q

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

A

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

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7
Q

What is required in the history for coding?

A

CHIEF COMPLAINT (required for any billing)

HPI
ROS
PMH
SH
FH
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8
Q

What is considered a comprehensive HPI?

A

> 3 of sxs & symptoms with other items

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9
Q

What is considered a complete ROS?

A

10+

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10
Q

What is considered a complete past history?

A

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

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11
Q

How is the code for Objective/History met?

A

Hx
ROS
PMH

2 of 3 must meet or exceed

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12
Q

How is the PE scored?

A

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

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13
Q

How many vital signs must you record?

A

need at least 3 vital signs

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14
Q

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

A

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

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15
Q

What are the 3 components of medical decision making?

A

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

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16
Q

What determines the level of service?

A

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

17
Q

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

A
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)
18
Q

What are the points for amount of data reviewed?

A

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

19
Q

What are minimal and low risk categories?

A

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)

20
Q

What is moderate risk (level 4)?

A

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

21
Q

What is high risk?

A

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

22
Q

What does SD dx documentation require?

A

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

23
Q

Where is SD documented?

A

OBJECTIVE (T4 F SR RR)

24
Q

What is required in documentation of plan?

A
consent
decision to perform OMT
disposition post procedure
response to tx
post procedure care
25
Q

How does billing of OMT in an office visit include?

A

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

26
Q

What are the 4 main parts of a produce note?

A

consent (benefits, risk, side effects, costs)

procedure description (body regions, techniques)

disposition (response to tx, any complications)

follow up plan (post procedure care)

27
Q

What is important about the procedure description?

A

may be fairly nonspecific

may be very specific

28
Q

What are important recommendations about E&M?

A

qualify the chief complaint

qualify the diagnosis