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E/M
E/M coding
| Question | Answer |
|---|---|
| E/M codes all begin with what two numbers? | 99 |
| What does E/M codes describe or identify? | place of service, nature of the presenting problem, time spent of the service, and the content/extent/level of the service. |
| What does E/M mean? | Evaluation and Management |
| E/M codes are found in what part of the manual? | beginning of CPT manual |
| Where are E/M codes generally found on an encounter form? | within the first section to complete |
| A ______ patient has not received any face -to -face professional services from this physician or another physician of the same specialty at your facility within the last three years. | new patient |
| A _______ patient has received face-to-face professional services from this physician or another physician of the same specialty at your facility within the last three years. | established patient |
| What components must be considered before determining the level of E/M service to report? | History, examination, and MDM |
| How many key components are there - name them | Three: History, examination, and MDM |
| When reporting an outpatient service for a new patient, does the coder need all three key components before reporting the E/M code? | All 3 key components are needed for a new patient for outpatient services. |
| When reporting an outpatient service for an established patient, does the coder need all three key components before reporting the E/M code? | The coder only needs 2 of the 3 key components to report an outpatient service for an established patient. |
| What are the contributing components? | Extent of counseling, Coordination of care with others, Nature of presenting problem(s), and Time |
| What are these? • Key components (KC)1. History2. Examination3. Medical decision making• Contributing components:4. Extent of counseling5. Coordination of care with others6. Nature of presenting problem(s)7. Time | seven components for E/M coding |
| What components are factored in, as applicable?Key Components or Contributing Components? | Contributing Components |
| What are the four elements of History? | 1). chief complaint (CC)2). history of present illness (HPI )3). review of systems (ROS)4). past,family,and social history (PFSH) |
| What is CC? | Chief Complaint |
| What is HPI? | History of Present Illness |
| What is ROS? | Review of Systems |
| What is PFSH? | Past Medical, Family and Social History |
| The ______ includes the symptoms, reason(s) for the visit, stated problem of the patient, signs, and diagnosis (if any were established prior to the visit). | CC - Chief Complaint |
| What are the eight elements of HPI? | location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms |
| HPI is based on the number of elements. It can be either _______ HPI or _____ HPI. | Brief or Extended |
| If the report has 4-8 elements, it will be an ______ HPI | Extended |
| If the report has 1-3 elements, it will be a _____ HPI. | Brief |
| Concerning HPI, what are these an example of: hand, head, foot, etc.. This is 1 of the 8 elements of HPI | location of the symptom |
| Concerning HPI, what are these an example of: burning, fullness. This is 1 of the 8 elements of HPI. | quality |
| Concerning HPI, what are these examples of: mild, intense, horrible; some may use a scale to decide this, such as "on a scale from 1-10, how would you rate your pain" This is 1 of the 8 elements of HPI | serverity |
| Concerning HPI, what is this an example of: "since last month" "since two days ago" This is 1 of the 8 elements of HPI and it explains how long the patient suffered. | Duration |
| Concerning HPI, what is this an example of: "after eating, after exercise"This is 1 of the 8 elements of HPI. | timing |
| Concerning HPI, what is this an example of: "when slumping," "only when sitting," "while running" This is 1 of the 8 elements of HPI and it identifies symptoms associated with a situation. | Context |
| Concerning HPI, what is this an example of: "sitting up straight," "cold compress" This is 1 of the 8 elements of HPI and it identifies the factors that make the condition better, or worse. | Modifying factors |
| Concerning HPI, what are these examples of: "hard to swallow, chest pain" This is 1 of the 8 elements of HPI and it tells of the problems that happen at the same time as another problem. | associated signs and symptoms |
| A _______ _________ ROS is a review of the one body system that is directly related to the chief complaint or presenting problem. | Problem pertinent |
| An ________ ROS is a review up to 9 additional systems | Extended |
| A ________ ROS is a review of 10 or more body systems | Complete |
| ________ is the inventory of the body systems | ROS |
| The number of systems reviewed and documented determines the _____ of ROS selected. | level |
| What is OS? | Organ System |
| What is BA? | Body Area |
| How many levels are there of PFSH? | 2: Pertinent and Complete |
| For a PFSH to be Pertinent, it must have how many items from the past? | 1 item from the past |
| For a PFSH to be Complete, it must have how many items from the past for an established patient? | 2 items from 2 areas |
| For a PFSH to be Complete, it must have how many items from the past for a new patient? | 3 items out of 3 areas |
| For a Complete PFSH, does it matter if the patient is new or established concerning how many items from the past should be obtained? | yes |
| What are elements of Past and Social History | Major illnesses/injuriesOperations HospitalizationsAllergiesImmunizationsDietary statusSexual historyOther relevant social factors |
| Are the types of History and the types of Examination the same? | yes |
| What are the types of History and Examination? | 1. Problem focused2. Detailed3. Expanded problem focused4. Comprehensive |
| Who developed the E/M Coding Guidelines? | AMA & CMS |
| Sometimes the case may mostly consist of counseling or coordination of care. What factor would the coder use to code this service? | Time |
| What must support the code selection? | Documentation |
| If the physician focuses on the CC, and a breif history of the present problem, what type of history is it? | problem focused history |
| If the physician centers his attention on the CC, obtains brief history of present problem, performs a problem pertinent ROS, what type of history is it? | expanded problem focused history |
| If the physician focuses on the CC, obtains an extended history of present problem, an extended ROS, and a pertinent PFSH, what type of history is it? | detailed history |
| If the physician documents the CC, does an extended history of present problem, complete ROS, and complete PFSH, what type of history is is? This is the most complex history type. | comprehensive history |
| If the exam is limited to the affected BA, or OS, identified in CC, what type of exam is it? | problem focused exam |
| If the exam is limited, made of affected BA or OS, and other symptomatic or related BA's / OS's, what type of exam is it? | expanded problem focused exam |
| If it is an extended exam concerning the affected BA, and other symptomatic or related OS, what type of exam is it? | detailed exam |
| If the exam is extensive, consists of a complete single-specialty exam or complete multisystem exam, what type of exam is is? This is the most complex exam. | comprehensive exam |
| What is the first visit? | initial |
| What is the second visit? | subsequent |
| When selecting a history level, the coder should select the ______ level. | lowest |
| What are the medical decision making complexity levels? | Straightforward decision makingLow-complexity decision making,Moderate decision making,High-complexity decision making |
| When selecting the MDM level, the coder will select the ______. In other words, select the level of the higest two. | majority |
| What is MDM based on? | the number of diagnoses or management options. The amount or complexity of data to review. The risks of complication or death if the condition goes untreated |
| What type of MDM is this: * minimal diagnosis and management* data and complexity are minimal/none* minimal risk | straightforward decision making |
| What type of MDM is this:* limited # of diagnoses & management* limited data* low risk | low-complexity decision making |
| What type of MDM is this:* multipul diagnoses & management * moderate complexity & data* moderate risk | moderate-complexity decision making |
| What type of MDM is this:* extensive diagnoses & management* extensive complexity & data* high risk | high-complexity decision making |
Created by:
CTUGirl
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