Electronic Coding from Medical Records/Ch. 5

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Testing your knowledge

Acronym E&M code stand for?

Evaluation and Management codes, subset of CPT 4 codes, to bill nearly every kind of patient encounter

How many levels are there for a category of E&M code?

There are four levels of E&M codes within each category

Name the three key components of an E&M code?

History, examination,and Medical decision making

How many levels are there for each key component?

There are four possible levels in each key component

How many key components determine the level of E&M code for an established patient?

for an established patient, the two key component with the highest level are considered and the lowest level of the two determines the E&M code.

HPI

History of Present Illness; chronological description of the patien's present illness; symptoms from previous encounter to present

ROS

Review of Systems; an inventory of body systems starting from head down

PFSH

Past, Family, Social History; obtained from patient or other family mamber

Explain how the level of a General Multisystem Exam is determined.

The labels list elements of the examination for each body system with a typographic character called a bullet (.) beside them. The number of the items with a bullet (.) that have been examined and are documented in the exam note determine the level of examination.

What determines the level of Risk?

The assessment of risk of selecting diagnostic procedures and management options is based on the risk during the immediately following any procedures or treatment. The highest level of risk in any one category (presenting problems, diagnostic procedures, or management options) determines the overall risk.

How many subcomponents (elements) of Medical Decision Making determine its level?

Two out three of the following: the number of diagnoses or management options, the amount or complexity of data, and the level of risk.

What makes up face-to-face time?

Face-to-face time incorporates the total time both before and after the visit such as taking patient history, performing the exam, reviewing lab results, planning for the follow up care, and communicating with other providers about the patient's case.

When does time become a factor in determining the level of E&M code?

When counseling or coordination of care represent more than 50% of the face-to-face time of the visit, time becomes a key or controlling factor to the level of E&M services.

What does the E&M button on the toolbar do?

The E&M calculator window will be invoked

How do you record an E&M code in the Patient Exam Note?

Locate and click on the button labeled "Post To Encounter". The E&M calculator window will close and the E&M code will be added into your note.

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