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cpt evaluation and management definitions

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chief complaint
a description of the problem that caused the patient to seek treatment usually stated in the patient words
clinical examples
Examples of the clinical situations associated with various E/M services that are listed in Appendix C.
concurrent care
the provision of similar services to the same patient by more than one physician on the same day
counseling
a discussion between the physician and a patient, family or both concerning diagnosis, recommended studies or test, prognosis, risks, and benefits of treatment, treatment options, patient and family education, and so on.
established patient
a person who has been treated previously by the healthcare provider, regardless of location of service, within 3 years
face-to-face time
The time a physician spends face-to-face with the patient or family; a component of E/M codes.
family history
Review of medical events in patient's family, including diseases that may be hereditary or put patient at risk.
history of present illness
HPI,, Chronologic description of patient's present illness from the 1st sign symptom or from previous encounter to present.
new patient
a person who has not received professional services within the past 3 years from physicians of the same specialty who belong to the same group practice
non-face-to -face time
The time spent doing work before and after seeing the patient or family; not a component of E/M codes.
past medical history
Patients past medical problems, conditions, or surgeries
professional services
Face-to-face services rendered by a physician and reported by one or more specific CPT codes. NOTE: This definition of professional services is used only to distinguish between new and established patients.
social history
age appropriate review of past and current activities that include signifigant information
special report
Documentation that supports the necessity for providing services that are unusual or not listed in the CPT manual.
system review
systems development phase that ensures the system operates and modifies the system so that it continues to meet changing business needs
unit/floor time
amount of time the provider spends at the patient's bedside and at managment of the patient's care on the unit or floor
unlisted service
an evaluation or management service provided to the p/t that does not have an associated cpt code