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Documentation

Patient information that is located in the medical record.

Key components

Level of service are based on ( history, examination, medical decission making)

Contributory factors

Level of service based on ( counseling, coordination of care, nature of presenting problem, and time).

Office, New Patient
According to the E/M Guidlines, the following categories/ subcategories must meet or exceed the stated level of the key components:

Hospital observation services
Initial hospital care
Office consultation
Inpatient consultation
Emergency department services
Initial nursing facility care
Domiciliary care, new patient
Home, new patient

Of the following categories/ subcategories, two of the three key components must be met or exceeded before the code may be assigned

Office, established patient
Subsequent hospital care
subsequent nursing facility care
Domiciliary care, established patient
Home, established patient

Four elements of a History

is the subjective information the patient tells the physician based on the four elements of a history- chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and / or social history (PFSH)

Chief Complain (CC)

is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, ot other factor that is the reason for the encounter, usually stated in the patient's words.

History of Present Illness (HPI)

Is chronological description of the development of the patient's present illness from the first sign and / or symptom or from the previous encounter to the present. The HPI may include the elements identified in the following example:
1. Location ( site on body)
2. Quality ( characteristics: throbbing, sharp)
3. Severity ( 1/10 or how intense)
4. Duration ( how long for problem or episode)
5. Timing ( when it occurs)
6. Context ( under what circumstances does it
occur)
7. Modifying factors ( what makes it better/
worse.)
8. Associated signs and symptoms ( what else is
happening when it occurs)

Review of Systems (ROS)

is an inventory of systems to reveal subjective symptoms that the patient either forgot to describe or which at the time seemed relatively unimportant.

Past, family, and/ or Social History (PFSH)

is the patient's past experience with illnesses, operations, injuries, and treatments; that includes significant information

History levels

four levels must me documented by the physician or NPP billing for the service.
1. Problem focused
2. expanded problem focused
3. detailed
4. comprehensive

1. Problem focused (history levels)

The physician forcuses on the chief complaint and a brief history of the present problem of a patient.

2. Expanded problem focused (history levels)

The physician focuses on a chied complaint, obtains a brief history of the present problem, and also performs a problem pertinent review of sytems. The expanded problem focused history does not have to include the past, family, or social history.

3. Detailed (history levels)

the physician focuses on a chief complaint, obtains an extended history of the present problem ( 4 or more of the 8 elements), and extended review of symptems, and a pertinent PFSH

4. Comprehensive (history levels)

This is the most complex of the history types: the physician documents the chief complaint, obtains an extended history of the present problem, does a complete review of systems, and obtains a complete PFSH.

Examination levels

The examination levels have the same titles as the history levels- problem focused, expanded problem focused, detailed, and comprehensive. The four levels are used to indicate the extent and complexity of the patient examination.

1. Problem focused ( examination levels)

examination is limited to the affected body area or organ system identified by the chief complaint.

2. Expande Problem focused ( examination levels)

A limited examination is made of the affected body area or organ system and other symptomatic or related body area(s)/ organ system(s)

3. Detailed ( examination levels)

An extended examination is made of the affected body area(s) and other symptomatic or related organ system(s).

4. Comprehensive ( examination levels)

This is the most extensive examination; it encompasses a general multi-system examination and should include findings about 8 or more of the 12 organ systems

Medical Decission Making (MDM) is basd on the complexity of the decision the physician must make about the patient's diagnosis and care.

Complexity of decision making is based on 3 elements:
1. Number of diagnoses or management options. The options can be minimal, limited, multiple, or extensive
2. Amount or complexity of data to review. the data can be minimal or none, limited, moderate, or extensive
3. Risk of complication or death if the condition goes untreated. Risk can be minimal, low, or high

Observation

a status used for the classification of a patient who does not have an illness severe enough to meet acute inpatient criteria and does not require resources as intensive as an inpatient but does require hospilization for a short period of time

Subsequent Hospital Care

codes are used by physicians to report daily hospital visits while the patient is hospitalized

Concurrent care

is being provided when more than one physician provides service to a patient on the same day for different conditions.

Attending physician

a doctor who, on the basis of education, training, and experience, is granted medical staff membership and clinical privileges by a health care organization to perform diagnostic and therapeutic procedures in the facility

A physician asking for the advice or opinion

is making a request for consultation and is the requesting physician

A physician giving the advice or opinion

is providing consultation and is the consultant. consultations can be provided to both outpatients and inpatients.

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