The 4 types of patient status are:
Describes a patient who has NOT beeen formally admitted to a health care facility.
One who has received FACE-TO-FACE professional services from the physician or another physician of the same specialty in the same group within the past 3 years.
Continued Intensive CAre Service
Under the notes or this subheading, the definition of low birth weight can be found.
S - Subjective= This is what the patient says.
O - Objective = Doctor's findings of the patient's condition are listed here as well as exam findings.
A - Assessment = Diagnosis are documented here.
P- Plan = Treatment procedure, therapy plan, or other management plan.
Social History element includes:
Use of drugs
Level of E/M service is based on
3 contributing factors (to E/M levels)
Coordination of care..
Nature of presenting problem.
3 key components that are present in EVERY patient case (except counseling encounter or time-based codes) and enable the coder to choose the appropriate level of service are:
MDM - Medical Decision Making
4 Elements of a History:
Chief Complaint (CC)
History of Present Illness (HPI) - MUST BE DOCUMENTED by PHYSICIAN in the medical record.
Review of systems (ROS)
Past, Family, and /or Social History (PFSH)
4 Levels of History type:
Expanded problem focused
4 levels of Medical Decision Making (MDM) Complexity
Complexity of Medical decision making (MDM) is based on the following 3elements that the physician must consider about the management of a patient's condition:
Number of diagnoses
Risk of morbidity(complication or death.
Amount of data (complexity)
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