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2012 Buck Step by Step Medical Coding Ch 15

2 Examples of Place of Service

Nursing Home

4 Examples of Type of Service

Newborn Care
Office Visit

4 Examples of Patient Status


New Patient

Patient who has not received professional services from physician or another physician of same specialty/subspecialty in same group within past 3 years


Patient who has been formally admitted to health care facility.

3 Key Components to E/M Level of Service

Medical Decision Making Complexity

4 Contributory Factors to E/M Level of Service

Coordination of Care
Nature of Presenting Problem

4 Elements of History

Chief Complaint
History of Presenting Illness
Review of Symptoms
Past/Family/Social History


Chief Complaint abbreviation


Review of Symptoms abbreviation


History of Present Illness abbreviation


Past/Family/Social History abbreviation

Chief Complaint

Patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.

History of Present Illness

description of current problem, includes location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms


Under what circumstances a symptom occurs

Modifying Factors

What circumstances make symptom better or worse

Associated Signs and Symptoms

What other symptoms occur when main symptom occurs

Review of Symptoms

An inventory of body systems obtained through a series of questions in which the patient reports signs or symptoms they are currently having or has had in past

Constitutional Symptoms

Usual weight, weight changes, fever, weakness, fatigue

Cardiovascular Symptoms

Chest pain
rheumatic fever
high blood pressure
varicose veins

Respiratory Symptoms

Chest Pain
sputum (color and quantity)
last chest xray
shortness of breath

Gastrointestinal Symptoms

rectal bleeding
change in bowel habits
food intolerance

Musculoskeletal symptoms

joint pain/stiffness
muscle pain
limitation in motor activity

Integumentary symptoms

changes in skin/hair/nails
breast lumps/dimpling/discharge

Neurological Symptoms

memory loss

Endocrine Symptoms

thyroid trouble
heat/cold intolerance
excessive sweating/thirst/hunger/urination
blood sugar levels

Hematologic/Lymphatic Symptoms

easy bruising/bleeding
past transfusions

Past History

Pt's past experience with illness/operations/injuries/treatments

Social History

Age-appropriate review of past/current activities including:
employment/occupational history
marital status/sexual history
use of drugs/alcohol/tobacco
education level

Family History

health status/cause of death of parents/siblings/children
Specific diseases related to CC, HPI, or ROS
hereditary diseases of family members

4 History Levels

Problem focused
Expanded problem focused

Problem Focused History

Brief HPI (1-3)
ROS- none
PFSH- none

Expanded Problem Focused History

Brief HPI (1-3)
Problem pertinent ROS (1 organ system)
PFSH - none.

Detailed History

Extended HPI (4+)
Extended ROS (2-9 organ systems)
Pertinent PFSH (1+)

Comprehensive History

Extended HPI (4+)
Complete ROS (10+ organ systems)
Complete PFSH. (2-3 elements depending on service)

How many elements are required to qualify for a given level of History?

3 of 3. (Lowest level is the level choice.)

4 Examination Levels

Problem focused
Expanded problem focused

Problem Focused Exam

Exam level with 1-5 bullets

Expanded Problem Focused Exam (1997)

Exam level with 6+ bullets

Detailed Exam (1997)

Exam level with 9+ bullets (eye specific)

Comprehensive Exam (1997)

Exam level with all 14 bullets

3 Elements of Medical Decision Making Complexity

Number of Problems
Amount of Data

4 Levels of Medical Decision Making



MDM Level with
Minimal dx/mgt options (1 problem point)
Minimal/no data (1 data point)
Minimal risk


MDM Level with
limited dx/mgt options (2 problem points)
limited data (2 data points)
low risk


MDM Level with
multiple dx/mgt options (3 problem points)
moderate data (3 data points)
moderate risk


MDM Level with
extensive dx/mgt options (4+ problem points)
extensive data (4+ data points)
high risk

What type of problem as the highest number of MDM points?

new problem, additional followup planned

Do you get multiple points if labs or xrays are ordered and/or reviewed?

No. One data point regardless of number of tests.

Do you get multiple points if labs are ordered AND reviewed?

Yes. One point for an ordered test, one point for a reviewed test.

How many elements are required to qualify for a given level of medical decision making?

2 of 3 (Majority is the choice.)


One of 3 Contributing Factors
Discussion of diagnosis, test results, impressions, and/or recommendations, prognosis, treatment options, follow-up, etc.

Coordination of Care

One of 3 Contributing Factors
For example, arranging admission to rehabilitation hospitals and nursing facilities.

Nature of the Presenting Problem

One of 3 Contributing Factors
Severity of Chief Complaint

Name the two types of time that a physician spends in the care of the patient

1. Direct/face to face
2. Unit/floor time

What are the two instances that time is considered for E/M services?

1. Time based codes (eg. Hospital D/C)
2. When 50% or more of time is spent in counseling/coordinating care.

How many key components must be present to code a given level of Office/Other Outpatient Services, New Patient?

3 of 3

How many key components must be present to code a given level of Office/Other Outpatient Services, Established Patient?

2 of 3

If a patient was seen in the office by his physician on Monday and during the appointment the physician decided to admit the patient to the Observation Unit of the local hospital, would you code both the office service and the observation service?

No. Services immediately prior to admission are bundled into the observation service and therefore not coded separately.

attending physician

The physician who admits the patient and is responsible for the patient during the stay in the inpatient facility.


A physician whose opinion and advice is requested by another physician, but does not take responsibility for the patient.

concurrent care

The care given to the patient by more than one physician at the same time. For example, a pulmonologist and a cardiologist both treating the patient for different conditions at the same time.

Give two examples of physicians who can admit patients to a hospital

1. PCP
2. Hospitalist


Hospital-based physician who only sees patients in the hospital and assumes the responsibility of the PCP for hospitalized patients.

Can Critical care and other E/M servcies may be provided to the same pt on the same day by the same physician?


True or False: Services for a pt who is not critically ill but is in a critical care unit are reported using Critical Care codes.

False. Use other appropriate E/M codes.

What is the determining factor in assigning a level of Critical Care Service?

Time per day
Subtract non-critical service time
If less than 30 minutes, use other E/M code

True or False: Many Critical Care codes have other services bundled into the code.


What modifier is used, per payer request, when reporting non-bundled services into the Critical Care codes


Nursing Facility

Not a hospital, but has inpatient beds and professional health care staff. Lowest level of nursing facility

Skilled Nursing Facility (SNF)

Staffed with physicians/nurses. Patients require more care than in standard nursing facility.

True or False: Prolonged service of less than 30 minutes total duration on a given date is not separately reported.

True. The work involved is included in the total work of the E/M code.

Three subheadings under the Prolonged Services subsection.

1. Prolonged Physician Service With Direct Patient Contact
2. Prolonged Physician Service Without Direct Patient Contact
3. Physician Standby Services

True or False: While reporting standby services for a patient, a physician may provide care/services to other patients.


Standby service may be coded for time spent by a physician proctoring another physician.


The codes within this subsection are used to report physician supervision of a patient under the care of a home health agency in a home, domiciliary, or equivalent environment and supervision of care for patients in a hospice or nursing facility.

Care Plan Oversight Services

The codes within this subsection are used to report services when the patient is not currently ill but receives services.

Preventive Medicine Services

This subsection is used to report coordination of care with other health professionals or in warfarin therapy management and coordination of care with other health care professionals

Case Management Services

Codes from this subsection are for care provided in the patient's home.

Home Services

This subsection is used by non-hospital settings with a professional staff that provides continuous health care services to patients who are not acutely ill.

Nursing Facility Services

Codes from this subsection are used to report the length of time the physician spends providing care to a critically ill patient.

Critical Care Services

Codes from this subsection are used by a hospital-based departments that are open 24 hours a day. They are often combined with Critical Care Services.

Emergency Department Services

Codes from this subsection are used when one physician asks another physician for an opinion about a patient

Consultation Services

Initial hospital care, Subsequent hospital care, and
Discharge services are all types of what E/M Service?

Hospital Inpatient Services.

If the physician thinks the patient is not ill enough to be formally admitted but still needs to be observed, this code subsection will be used.

Hospital Observation Services.

This subsection of codes could be the physician's office or other ambulatory facility, such as the outpatient surgery center at a hospital. These codes cannot be used once the patient has been admitted to a health care facility.

Office and Other Outpatient Services

This type of Preventive Medicine Services code is used when a patient is seen specifically to promote health, for example a diet/exercise program.

Counseling Risk Factor Reduction and Behavior Change Intervention.

True or False: If a significant problem is encountered during a preventive examination, additional E/M codes are used to report further services


Coding Preventive Medicine Services is largely based on what factor?

Age of the patient.

The 2 types of Non-Face-To-Face Physician Services

1. Telephone Services
2. On-line Medical Evaluation

Codes from this subheading cannot originate from an E/M service that was provided within the previous seven days and cannot lead to an E/M service within the next 24 hours or the next available appointment. The services are reported based on the time documented in the medical record.

Non-Face-To-Face Physician Services

Use codes from this subheading to report evaluation and management services provided to a normal newborn infant. These services may be provided in a hospital or in a birthing center. The services are reported on a per day basis of initial or subsequent service.

Newborn Care Services

Inpatient neonatal and pediatric critical care codes are based on what factor?

The age of the patient. Neonate = 28 days or younger. Pediatric = 29 days through 24 months or 2-5 years.

What subsection is used when a neonate or infant is not considered critically ill but still needs intensive observation?

Initial and Continuing Intensive Care Services


Very Low Birth Weight (less than 1500 grams)


Low Birth Weight (1500-2500 grams)

This subsection has one code, 99499, that is used to indicate that there is no other code that accurately represents the services provided to the patient.

Other Evaluation and Management Services

What must always accompany an unlisted E/M service code?

Special report

A patient comes into your physician's office for a physical examination for a life insurance policy. What group of codes would you use to report this service?

Special evaluation and management services

Which government group is responsible for the Medicare program?

Centers for Medicare and Medicaid Services

The Documentation Guidelines apply only to this group of codes.

E/M Codes

What are the three years that Documentation Guidelines were published?


E/M services represent which percent of all services provided to Medicare and Medicaid patients?


CMS stands for

Centers for Medicare and Medicaid Services

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