Evaluation and Management (E/M Services) Chapter 11

Three factors of E/M Codes

1) Place of Service (Office, Hospital, ER, Nursing Home) 2) Type of Service (Consultation, Admission, Newborn care, Office Office Visit) 3) Patient Status (New, Established, Outpatient, Inpatient)

E/M Codes Established Patient

2 out of 3) Level E/M Code History Examen MDM Time 1 99211 N/A N/A N/A 5 2 99212 PF PF SF 10 3 99213 EPF EPF Low 15 4 99214 DET DET Mod 25 5 99215 COMP COMP High 40

E/M Codes New Patient

3 years ( 3 out of 3) Level E/M Code History Examen MDM Time 1 99201 PF PF SF 10 2 99202 EPF EPF SF 20 3 99203 DET DET Low 30 4 99204 COMP COMP Mod 45 5 99205 COMP COMP High 60

Office Visit

A face-to-face encounter in an office between the physician and patient

Consultation

Advice or opinion from one Physician to another

Admission

Attention to an acute illness or injury that results in hospitalization

The patient record indicates that a problem focused history and examination were done. When this is combined with the level of decision making complexity you arrived at for this patient, what is the correct CPT code for the case?

CPT Code: 99217

4 Elements of a History

Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family and/or Social History (PFSH)

When care is provided for similar services (e.g. hospital visits) to the same patient by more than one physician on the same day for different conditions, the care is

Concurrent

Examination Elements

Constitutional (OS) Body Areas (BA) Organ System (OS)

Those services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation and/or treatment of a patient is a(n)____________________whereas the physician who has primary responsibility for the patient in the hospital is called__________________

Consultation, attending

Counseling and coordination of care are what kind of factors in most cases?

Contributory Factor

A discussion with a patient and/or family concerning one or more of the following areas diagnostic results, impressions and/or recommended diagnostic studies; prognosis; risk and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education is

Counseling

When critically ill patients in medical emergencies require the constant attendance of the physician (e.g. cardiac arrest, shock, bleeding, and respiratory failure) to stabilize them, what kind of care is needed?

Critical care services

There is no distinction made between the new and established patients in this service department of a hospital

Emergency Department

Newborn Care

Evaluation and determination of care for a newborn infant

Time that is used as a guide for outpatient services is what kind of time?

Face-to-Face

The 4 types of Medical Decision Making (MDM) In order from most to least complex, are as follows:

High Moderate Low Straightforward

List the five types of presenting problems from the most risk and least recovery to least risk and most recovery:

High Severity Moderate Severity Low Severity Selt-Limited Minimal

3 Key Components

History Examination Medical Decision Making

The Level of Service are based on:

Key Components (History, Exam, Medican Decision) and Contributory Factors) (Counseling, coordination of care, nature of presenting problem)

Complexity of Medical Decision Making is based on three

Key Elements and Contributory Factors

The patient's______________________________ will reflect the number of systems examined by a brief statement of the findings.

Medical Record

Analyze this case with CPT book. 40 years-old male patient (new) is evaluated for contusion of a finger. The history and examination were problems focused. a) Diagnosis and management option for contusion of finger. (Options can be minimal, limited, multiple or extensive) Diagnosis and management options:

Minimal

b) Risks if left untreated. (Risk can be minimal, low, moderate, or high) Risks:

Minimal

Level of Risk

Minimal (Level 1) Low (Level 2) Moderate (Level 3) High (Level 4)

Data to review to provide service. (Data can be minimal/none, limited moderate or extensive) Only data available are current. Information obtained during the visit. Data:

Minimal/None

If the physician who is standing by does so for 25 minutes, can he or she round the time up to 30 minutes for reporting purposes?

No

Inpatient

One who has been formally admitted to an acute health care facility

Outpatient

One who has not been formally admitted to a health care facility

New Patient

One who has not received professional service from the physician or another physician in the exact same specialty and subspecialty in the same group within the last 3 years

Established Patient

One who has received professional service from the physician or another physician in the exact same specialty and subspecialty in the same group within the last 3 years

History Levels

Problem focused Expanded Problem focused Detailed Comprehensive

An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a(n)

Review of System

All three of the elements have been met to qualify this patient for what level of decision making complexity?

Straightforward

The history is the ____________________ information the patient tells the physician.

Subjective

What is the name for the assumption of the total or specific care of a patient from one physician to another that does not constitute a consultation?

Transfer of Care

Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time?

Unit/Floor Time