Place of service, type of service, and patient status.
Place or setting in which the service was provided is called?
Place of service
There are different codes for outpatient and inpatient settings.
Kind of service provided is called?
Type of service
Codes are divides based on the types of service.
How many types of patients statuses are there?
Has not received professional services from the physician or another physician of the same specialty and sub specialty in the same group practice within the past 3 years.
has received professional services from the physician or another physician of the exact same specialty and sub specialty in the same group practice within the past 3 years.
Has not been formally admitted to a health care facility.
Has been formally admitted to a health care facility.
The three key components are the history, examination,and a medical decision-making complexity.
Is the subjective (patient provided) information that the physician elicits regarding to the chief complaint
There are four elements of history.
What are the four elements of history?
Chief Complaint(CC), History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and Social History (PFSH)
History of Present Illness
Review of Systems
Past,Family, and Social History
A concise statement describing the symptom,problem,condition,diagnosis,physician recommended return or other reason for the encounter/ visit usually in patient's words is called a
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
History of Present Illness
Site on the body
Characteristics, such as throbbing, sharp
How intense or on a scale of 1/10
How long for this problem or episode
When does it occur
Under what circumstances does it occur
Modifying factors means
What makes it better or worse
Associated signs and symptoms means
what else is happening when it occurs
The extent of the HPI as problem focused, expanded problem focused, detailed, or comprehensive is based on the physician's professional judgement depending on the needs of the patient.
What are the two levels of HPI
Brief (1-3 elements) and extended(4 or more elements)
The problem-focused and expanded problem-focused levels of history contain a brief review of the problems surrounding why the patient is being seen that day.
The detailed and comprehensive levels of history contain an extended review of the HPI elements.
An inventory of the body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced.
Review of Systems
A review of the patient's past experience with illnesses, injuries, and treatment .
A review of medical events in the patient's family
An age appropriate review of past and current activities
is a review that is focused on the organ system involved in the chief complaint
Problem pertinent ROS
Includes a review of the system directly involved in the chief complaint, plus related (up to nine) systems.
Includes at least 10 of the 14 Organ Systems
is a review of the pas, family,and social history of the patient
What are the two levels of PFSH?
pertinent and complete
What are the four levels of history?
problem focused, expanded problem focused, detailed, and comprehensive
When the physician focuses on the CC and a brief history of the present problem of a patient.
When the physician focuses on a CC, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.
Expanded problem focused
When the physician focuses on a CC and obtains an extended history of the present problem.
When the physician documents the CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH
Is the subjective information the patient provides the physician
Objective information that the physician gathers.
Head (Including face)
Chest (Including Breast and axillae)
Genitalia, groin,and buttocks
Otolaryngologic (ears,nose,mouth, and throat)
Hematologic/ Lymphatic/ Immunologic
What are the four levels of examination?
Problem focused,expanded problem focused, detailed, and comprehensive
Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA
A limited examination of the affected area BA or OS and other related BAs or OSs. It involves a limited examination of 2-7 BAs or OSs
Expanded problem focused
An extended examination of the affected BAs or related OSs. It involves an extended examination of 2-7 BAs or OSs
Encompasses at least 8 OSs without counting BAs
The levels of examination include both body areas (BA) and organ systems (OS), with the exception of the comprehensive examination.
True or False
When abstracting a medical record count both the
BAs and OSs`
Constitutional on the exam count as 1 OS and that OS counts when calculating the examination.
True or False?
the key component of MDM is based on the__________ of the decision the physician must make regarding the patient's diagnosis and care.
Complexity of decision making is based on three elements.
True or False?
What are the three elements of decision making?
number of diagnoses or management options, Amount and/or complexity of data to review, and risk of complication and/or death if the condition goes untreated.
What are the four types of MDM complexity?
straightforward, low, moderate,and high
Blood pressure, sitting
Blood pressure, lying
Minimal diagnosis and/or management options, minimal or none for the amount and complexity of data to be reviewed,and minimal risks to the patient of complications or death if untreated.
Limited number of diagnosis and/or management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated
multiple diagnosis and or management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.
extensive diagnosis and or 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.
____________ factors are those conditions that help the physician to determine the extent of history, examination, and decision making necessary to treat the patient
What are the three contributory factors?
counseling, coordination of care, and the nature of the presenting problem.
Involves discussion of diagnostic 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 education.
A physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long- term nursing facility.
Coordination of care
a disease, conditon, illness, injury, symptom, sign finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter
How many types of presenting problems are there?
What are the five types of presenting problems?
Minimal, Self-limited, low severity, and moderate severity
A _______ problem is a blood pressure reading, a dressing change,or another service that can be performed without the physician being immediately present.
also called a minor presenting problem
The risk of complete sickness without treatment is low, there is no risk of death without treatment, and full recovery without impairment is expected.
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,
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.
What are two measurements of time?
Face-to-face time and unit/floor time
_________ time is the time a physician spends directly with a patient during an office visit obtaining the history, performing an examination, and discussing results.
Inpatient time is measured as ________ time and is used to describe the time a physician spends in the hospital setting dealing with the patient's care.
_______ services are based on time
More than one physician can use the subsequent care codes on the same day. This is called
Who maintains the primary responsibility for the overall care of the patient,no matter how many other physicians are providing services to the patient, unless a formal transfer of care has occurred.
These codes are reported for either inpatients or outpatients who are admitted and discharged on the same day.
Observation or Inpatient Care Services (99234-99236)
______________ are reported on the final day of services for a multiple-day-stay in a hospital setting.