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Know what E/M services are Services that the physician provides to evaluate patients that were previously referred to as office, hospital or home visits. How many key components need to be present to assign a code New patient encounter three of three need to be present Established patient only requires two of three What are the key components used to I.D. the correct level of service History physical examination medical decision making What are the contributory factors counseling coordination of care nature of presenting problem face-to-face time New patient patient has not received any professional services from the physician within the past three years Established patient patient has been seen in the office in the past three years Inpatient patient is formally admitted to the hospital what is a consult? services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem. what is a follow-up? patient comes back after the initial visit How do you code a consult & a follow-up? After the consult is complete and the phsyician assumes management of all patients conditions, then use an established patient code for the follow-up visit. Consults are coded in the preventative medicine sectiion initial new patient consult first visit by consulting doctor follow-up consult doctor has not assumed responsibility for the patients condition (2nd visit) Confirmatory consult consulting doctor offers an opinion about the treatment plan after a diagnosis has been made Office/outpatient consult when a patient is seen in the office by a specialist what is a referral? the transfer of the total or specifica care of a patient from one physician to another for known problems How can a referral be used? a referral is also an authorization for a patient to receive services What criteria needs to be met in order to bill 99211? face to face contact with the patient doctor must be in the office separate service must be provided (injection) proper documentation What bundled services means? codes that are grouped together that are related to a procedure What is preventative medicine? services provided to prevent the occurance of illness, injury and disease. Such as vaccine immunizations, routine physical exams and counseling How is preventative medicine categorized? according to the patients age Inpatient patient is formally admitted to the hospital outpatient patient receives services in a health care facility and goes home the same day observation status patient is admitted under observation, but has not formally been admitted to the hospital. There are 24 hours to make a decision to admit fully or discharge How many codes are there in the CPT code 5 digits what does CPT stand for? Current Procedural Terminology How many levels of HCPCS are there? there are 3 levels How often are CPT codes revised? annualy Who developed HCPCS codes? Centers for Medicare and Medicaid services (CMS) emergency care health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part Critical care intensive care provided in a variety of acute life-threatening conditions requiring constant bedside attention by a physician Counseling aspect of preventative medicine. Discussion between the physician and a patient, family or both concerning the diagnosis, recommeded studies or tests, treatmen options, risks and benefits of treatment, treatment options, patient and family education Modifier In CPT coding, a two-digit add-on number placed after the usual procedural code number to indicate a procedure or service has been altered by specific circumstances consultation services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem