Reimbursement

Question 1

General principles of Documentation

Answer 1

If you didn’t document it, then you didn’t do it and it is fraud to bill for it. Medical decision making leading to patient care is important to include in the documentation.

Question 2

4 types of E/M visits

Answer 2

1. Problem focused
2. Extended problem focused
3. Detailed
4. Comprehensive

There are 3 components to each visit. Each visit requires different levels of documentation.

There are also two different federal guidelines, 1995 and 1997.

Question 3

3 E/M Components

Answer 3

1. Medical History
2. Physical Exam
3. Medical Decision Making

Question 4

Components of Medical History

Answer 4

1. Chief Complaint, in pts own words (my wrist hurts)
2. History of present issue- when did it start, what is the pain like, what makes it better/worse, etc. HPI must be documented and reviewed by provider- You cannot have a student obtain history and use theirs. you have to take their own

Question 5

Problem Focused Components

Answer 5

CC: required
HPI: brief
PFSH and ROS not required

Question 6

Comprehensive Components

Answer 6

CC: Required
HPI: Extensive
PFSH: Complete 3/3
ROS: Complete, 10