your job is to code from what is documented in medical record, OPTIMIZE - NEVER MAXIMIZE,accurately report documented svcs
Types of svc
consultation, office svcs, and hospital svcs
Integral factors when selecting E/M codes
place of svc, type of svc, pt status
place of svc
explains setting of svc: office, ER, nursing home
type of svc
physicians provide many types of svc: consultations, admissions, office visits
the four status types are: new pt, est. pt, outpt, inpt.
has not rcv'd any professional svc in last 3 years from the same physician or another physician of the same specialty and in the same group. new pts. are more labor-intensive for physician, medical staff, and clerical staff
Has rcv'd professional svcs in last 3 yearsfrom the same physician or another physician of the same specialty in the same group.
Medical record available with current, relevant info
one who has not been admitted to health care facility
one who has been formally admitted to a hospital or nursing home. physician dictates: admission orders, H&P (history and physical), requests for consultations
Levels of E/M svc based on
skill required to provide svc, time spent, level of knowledge necessary to treat the pt, effort required, responsibility required/assumed
four elements of a history
1.chief complaint (cc), 2.history of present illness (hpi), 3. review of symptoms (ros), 4. past,family,or social history (pfsh)
Chief complaint (CC)
subjective: reason for encounter or presenting problem: pts current complaint in pts own words, documented in medical record for each encounter
history of present illness (HPI)
subjective: description of developement of current illness, ex: date of onset, pt describes HPI, provider must personally document
review of systems (ROS)
questions being posed to the pt to identify signs and symptoms that have been or are being experienced relating to the HPI.
past, family, and social history
contains relevant info about past illnesses, injury, or treatment, including: major illnesses/injuries, operations, hospitalizations, allergies, immunizations, dietary status, current medications
health status or cause of death of family members: parents, siblings, children. family history items related to CC: hereditary diseases. social history: review of past and current activities: marital status, employment, occupational history, use of drugs/alcohol, educational activities, sexual history, other relevant or contributory factors.
four history levels
problem focused (PF), expanded problem focused (EPF), detailed (D), comprehensive (C).
problem focused history
CC, brief HPI 1-3, no ROS, no PFSH
Expanded problem focused history
CC, brief HPI 1-3, problem focused ROS 1, No Pfsh
CC, Extended HPI 4+, problem pertinent ROS, extended to include a limited number of additional systems 2-9, pertinent PFSH directly related to problem 1
CC, Extended HPI 4+, complete ROS directly related to CC 10+, plus review of atleast 8 additional systems, complete PFSH, summary of elements required for each level of history 2-3
Medical decision making complexity (MDM)
Mngmnt options, data reviewed, risks
based on number of possible diagnosis, Levels: minimal, limited, multiple, or extensive
Laboratory, radiology; any test/procedure results are documented along with the data reviewed and the identity of the reviewer in medical record, old medical records (data) from others may be requested and reviewed, levels: minimal, limited moderate, or extensive.
risks of morbidity (poor outcome), complications, or mortality (death) associated with problem, diagnostic procedure. other diseases or factors (co-morbidities) : diabetes, extreme age; urgency relates to risks: myocardial infarction, ruptured appendix; Levels: minimal, low, moderate, or high
Four levels of MDM complexity
Straightforward MDM, Low-complexity MDM, Moderate-complexity MDM, high-complexity MDM
number of diagnoses or management options: minimal, amount of complexity of data: minimal/none, risk of complications or death: minimal.
number of diagnoses or management options: limited, amount or complexity of data: limited, risk of complications or death: low
number of diagnoses or management options; multiple, amount or complexity of data: moderate, risk of complications or death: moderate
number of diagnoses or management options: Extensive, amount or complexity of data: extensive, risk of complications or death: high
counseling, coordination of care, nature of presenting problem
levels of presenting problem
minimal presenting problem(might not require a physician), self-limiting or minor presenting problem(self-limiting problems are minor and with a good outcome and no complications predicted), low-severity presenting problem(without treatment low-risk), moderate-severity presenting problem(without treatment moderate risk), high-severity presenting problem(without treatment high risk), time(direct face-to-face: physician or NPP and patient together, calculated for code assignment beginning and ending times documented in medical record, unit/floor: time spent by physician on pt's floor or unit, also at pts bedside)
Use of E/M code
Codes are grouped by type of svce and place of svce: consultation, office visit, hospital admission; different codes are required for various levels or svce assignment
Selection of level of E/M services
for the following categories/subcategories, all three of the key components must meet or exceed the level stated in the code description: office or other outpatient services, new patient, hospital observation services, initial hospital care, office consultation, inpatient consultation, Emerg.dept. services, initial nursing facility care, other nursing facility services, domiciliary, rest homes, or custodial care services, new patient, home services, new patient; office or other outpatient services, est. patient, subsequent hospital care, subsequent nursing facility care, domiciliary, rest home, est.pt, homes services, est. pt.