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# BAS 02 E/M Section
| Question | Answer |
|---|---|
| New Patient | Has not received any professional services from the physician or another physician of the same specialty in the same group pracctice, within the past 3 yrs. |
| Established Patient | One who has received medical services from the physician or another physician of the same specialty in the same group practice, within the past 3 yrs. |
| Chief Complaint (CC) | The reason for the visit. Usually in the patient's own words. |
| Concurrent Care | Similar services to the same patient by more than one doctor on the same day. |
| Counseling | A discussion with the patient and/or family concerning: Dx results, treatment options, prognosis, risk factors, education, family history. |
| History of Present Illness (HPI) | Chronological description of the patient's condidition from the first sign/symptom to the present. |
| Key components of E/M levels of service | KEY descriptors: History | Examination | MDM (medical decision making) |
| In order to choose a level of E/M service all three KEY components must be presnet: | History Examination MDM (Medical Decision Making) |
| Nature of Presenting Problem | This is the reason the patient is in to see the doctor evaluated by doctor involvement, prognosis, morbidity and mortality. |
| Presenting problem is minimal | May not require the doctor but the doctor supervises the procedure. |
| Presenting problem is: Self-limited or minor | Transient in nature. Condition is self limited. Will not permanently alter health. |
| Presenting problem is: Low Severity | low risk of morbidity without treatment. Full recovery without functional impairement is expected. |
| Presenting problem is: Moderate severity | moderate risk of morbidity uncertain prognosis prolonged functional impairment is probable. |
| Presenting problem is: High severity | morbidity is high without treatment. high risk of mortality without treatment. Severe prolonged impairment is probable. |
| Past History | Prior illness, injury, operations, meds, allergies, hospitalizations, vaccines |
| Social History | Marital status/living arrangements, employment/history, drug use, education, sex history |
| System Review (Review of Systems, ROS) | Observation of all body systems including consitiutional symptoms like fever, weight los, blood pressure, etc. |
| TIME | Face-toFace time: Office exam, counseling unit/floor time: Hospital , Inpatient visit |
| Face to Face Time | Includes: Hx, exam, counseling, time before the visit and time after the visit. |
| Unit/Floor time | Time required to: review the chart, examine patient in room, write notes, etc. |
| Special Report | written report addressing the medical need, type of procedure, time, equipment. |
| To qualify for a particular level of EM seervice | All key components must be present. Two of the key components must meet or exceed the requirements Counseling requirea more than 50% of face to face time or unit/floor time. |
| Subjective | Reported by the patient but not measureable. (headache, nausea, past medical problem) |
| Ojective | Measureable by the clinic. Vital signs, Xrays, blood tests, Scans, etc. |
| rule out | A doctor uses this to include diseases that have not been confirmed. (arthritis, rule out: rheumatoid arthritis). The "rule out" means to keep rheumatoid arthritis as a possible Dx. |
| morbidity | disease |
| mortality | death |
| ROS | review of systems |
| HPI | history of present illness |
| PFSH | Personal, Family, and Social History |
| E/M | Evaluation and management |
| Tx | treatment |
| Hx | history |
| Sx | symptom |
| If a Dx is made on a patient, the doctor needs to have.... | objective evidence in the form of Xray, blood tests or exam. (stuff that was measured) |
| comorbidity | a disease or condition that exists with another disease or condition |
| medical necessity | the need for objective evidence to support a treatment for the patient. The Dx and Tx is pertinent to the HPI, PFSH and Hx of the patient. |
| V code | A code that identifies a visit for someone not complaining of something new. These are health checkups even if the person is diagnosed with a disease. |
| When the patient answers questions regarding past diseases and surgeries the doctor that reviews the survey gets credit for... | ROS |
| Doctors are paid for reviewing the chart before the patient arrives | TRUE |
| Doctors are paid for writing notes in the chart. | TRUE |
| V codes are always primary | FALSE. These codes are secondary when the health status is not currently the illness or injury. Example, Pt. wants to know what affect Family History might have on health status. |
| V codes are for coding for new problems that arise in a patient's health. | FALSE. These codes are used to show that follow-up and aftercare visits have been provided to the patient. |
| ROM | range of motion |
| PMH | Past medical history: surgeries, treatments, medications, conditions |
| c/o | complains of |
| pt. | patient |
| What type of evidence should be in the chart for a 99205 | CC, HPI, PMH, FH, SH |
| What type of evidence should be in the chart for a 99201 | CC and what was done or observed |
| What type of evidence should be in the chart for a 99211 | CC and what was done or observed |
| What should be in the chart for a 99203 | CC, HPI, PMH, FH, SH, Expanded ROS involves more than one body system. |
Created by:
rjmtoss