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Code assignment in the E/M section varies according to three factors:

Place of service, type of service, and patient status

Place of service

This is the first factor, which explains the setting in which the services were provided to the patient. Examples: physican's office, hospital, emergency department, nursing home.

Type of service

This is the second factor, which is the reason the service is requested or performed. Examples: consultation, admission, newborn care, and office visit.

Patient status

This is the third factor and examples are new, established, outpatient, and inpatient.

Consultation

is a written or verbal request from one provider/physician to another to obtain an opinion and/or advice about a diagnosis or management options.

admission

is attention to an acute illness or injury that results in admission to a hospital.

newborn care

is the evaluation and determination of care management of a newly born infant.

office visit

is a face-to-face encounter between a physician and a patient to allow for primary management of the patient's health care status.

new patient

who has not received professional face-to-face services from the physician or another physician of the same specialty in the same group within the past 3 years.

Established patient

who has received professional face-to-face services from the physician or another physician of the same specialty in the same group within the past 3 years.

outpatient

who has not been formally admitted to a health care facility or a patient admitted for observation.

inpatient

who has been formally admittd to a health care facility.

Medical records documentation

this is use to evaluation of the patient's treatment, communications regarding the patient's health care, reimbursement claims, review of the use of the health care facility, research/education, and legal documentation.

key components

are history, examination, and medical decision making complexity.

contributory factors

are counseling, coordination of care, nature of presenting problem, and time.

levels of service

are based on key components and contributory factors.

History information

is the subjective information the patient tells the physician based on the four elements ( chief complaint; history of present illness; review of systems; and past, family and social history.)

Chief complaint

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

history of present illness

is a 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.

Review of systems (ROS)

is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.

past history

is the patient's past experience with illness, operations, injuries, and treatments.

social history

is an age-appropriate review of past and current activities that includes significant information

family history

is the review of medical events in the patient's family that includes significant information.

History levels

are four levels; which is based on the extent of the history during the history-taking portion of the physician-patient encounter. Levels are problem focused, expanded problem focused, detailed, and comprehensive.

Problem focused history level

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

expanded problem focused history level

the physician focuses on a chief complaint, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.

detailed history level

The physician focuses on a chief complaint, obtains an extended history of the present problem, an extended review of systems, and a pertinent PFSH.

Comprehensive history level

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

subjective information

information the patient tells the physician.

objective information

hands-on, which are findings observed by the physician.

problem focused examination level

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

expanded problem focused examination level

a limited examination is made of the affected body area or organ system and other symptomatic or related body areas/ organ systems.

detailed examination level

an extended examination is made of the affected body areas and other symptomatic or related organ system.

comprehensive examination level

it encompasses a general multi-system examination, which is the most extensive examination.

Medical decision making complexity levels

are straightforward, low, moderate, and high

straightforward decision making

minimal diagnosis and management options, minimal for the amount and complexity of data to be reviewed, and minimal risk to the patient of complications or death if untreated.

low-complexity decision making

limited number of diagnoese and management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.

moderate-complexity decision making

multiple diagnoses and management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.

high-complexity decision making

extensive diagnoses and management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.

Minimal level of risk

one self-limited or minor problem.

low level of risk

two or more self-limited or minor problems.
One stable chronic illness.
Acute, uncomplicated illness or injury.

moderate level of risk

one or more chronic illness with mild exacerbation, progression, or side effects of treatment.
Two or more stable chronic illnesses.
Undiagnosed new problem with uncertain prognosis.
Acute illness with systemic symptoms.

High level of risk

one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment.
Acute or chronic illnesses or injuries that pose a threat to life or body function.
An abrupt change in neurologic status.

counseling

is a service that physicians provide to patients and their families. It involves discussion of daignostic results, impressions, and recommended diagnostic studies; prognosis; risks and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family eduation.

Coordination of care

a physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long-term nursing facility.

presenting problem

is the patient's chief complaint or the situation that leads the physician to determining the level of care necessary to diagnose and treat the patient.

minimal presenting problem

a problem may not require the presence of the physician, but a service is provided under the physician's supervision

self-limited presenting problem

a self-limited problem runs a definite and prescribed course, is transient ( it comes and goes), and is not likely to permanently alter health status, or the presenting problem has a good prognosis with management and compliance.

low severity presenting problem

the risk of complete sickness ( morbidity) without treatment is low, there is little or no risk of death without treatment, and full recovery without impairment is expected.

moderate severity presenting problem

the risk of complete sickness without treatment is moderate, there is moderate risk of death without treatment, and an uncertain prognosis or increased probability of impairment exists.

High severity presenting problem

the risk of complete sickness without treatment is high to extreme, there is a moderate to high risk of death without treatment, or there is a strong probability of severe, prolonged functional impairment.

Direct face-to-face

is the time a physician spends directly with a patient during an office visit obtaining the history, performing an examination, and discussing the results.

unit/floor time

is used to describe the time a physician spends in the hospital setting dealing with the patient's care. It includes care given to the patient at the bedside as well as at other settings on the unit or floor.

observation

is the status used for the classificaiton of a patient who does not hava an illness severe enough to meet acute inpatient criteria and does not require resources as intensive as an inpatient but does require hospitalization for a short period of time.

observation care discharge services

This code is used only with patients who are discharged on a day that follows the first day of observation.

subsequent observation care

this code report the physician's services for day 2 to the date of discharge. It also indicate the time the physician typically spends providing the service.

inital observation care

This code designate the beginning of observation status in a hospital. It also includes development of a care plan for the patient and periodic reassessment while on observation status. Observation admission can be reported only for the first day of the service.

Initial hospital care

This codes are used to report the initial service of admission to the hospital by the admitting physician. It also reflect services in any setting that are provided in conjunction with the admission to the hospital.

Subsequent hospital care

This code is used by physicians to report daily hospital visits while the patient is hospitalized.

Concurrent care

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

attending physician

is 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.

observation or inpatient care services

code report services provided when the patient is admitted and discharged on the same day. This code include both the admission service and discharge service.

hospital discharge services

this code is reported on the final day of services for a multiple-day stay in a hospital setting.This code are based on the time spent by the physician in handling the final discharge of the patient.

outpatient consultations

this code is reported to consultative services provided to a patient in an office setting.

Inpatient consultations

this code is reported to services by physicians in inpatient settings.

Emergency department services

this code is assigned for new or established patients when services are provided in an emergency department.

critical care services

this code identify services that are provided during medical emergencies to patients over 71 months of age who are either critically ill or injured. This codes are based off of time.

Nursing facility

is not a hospital but does have inpatient beds and a professional health care staff that provides health care to persons who do not require the level of service provided in an acute care facility.

intermediate care facility

provides regular, basic health services to individuals who do not need to degree of care or treatment provided in a hospital or a skilled nursing facility.

long-term facility

describes health and personal services provided to ill, aged, disable, or mentally handicapped individuals for an extended period of time.

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