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14 terms

MIBG WEEK 3

STUDY
PLAY
The 4 types of patient status are:
New
Inpatient
Established
Outpatient
outpatient
Describes a patient who has NOT beeen formally admitted to a health care facility.
Established patient
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.
SOAP
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:
History
Employment
Education
Use of drugs
ROS -
Review of Systems
Level of E/M service is based on
Documentation
Key Components
Contributing factors
3 contributing factors (to E/M levels)
Counseling
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:
History
Exam
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:
Problem focused
Expanded problem focused
Detailed
Comprehensive
4 levels of Medical Decision Making (MDM) Complexity
Straightforward
Low
Moderate
High
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)