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LESSON 4 EVAL. MAGMT

EVALUATION MANAGEMENT

QuestionAnswer
What are the levels of Evaluation Management E/M services based on? Documentation, key components and contributing factors.
Who must document the HPI in the medical record? The physician
What is the difference between subjective and objective in the examination? Subjective the patient gives the physician information regarding the problem. Objective is the findings observed by the physician during the examination.
What are the three elements of medical decision making? Number of diagnosis or management options. Amount and/or complexity of data to review. Risk of complication or death if the condition goes untreated.
What is a consultation? A written or verbal request from one provider/physician to another to obtain an opinion and/or advise.
Critical care codes are reported based on ? The time the physician spends providing critical care to the patient.
When a physician performs a preventative care service, the extent of the exam is determined by ? The age, gender, new patient, established patient, risk factor reduction and behavior change intervention.
What is the age of a neonate? 28 days or younger.
What determines an established patient from a new patient? A new patient is one who has not received services from the physician within 3 years. An established patient is one who has received services from a physician within 3 years.
What is the difference between an inpatient versus an outpatient status? Inpatient is one who has formally admitted to the hospital fa. Out patient is one who receives emergency department services, but has not been admitted to the hospital.
What are the three factors of the evaluation management E/M codes? Place of service, type of service, patient status.
What is a chief complaint? Medical term to describe the primary problem or symptom. Why is patient here.
What is a modifier 25? Modifier 25 is used to report evaluation management E/M services on a day when another service was provided.
Give examples of each history of Present Illness: LOCATION: site of body, TIMING: when it happened, QUALITY: pain, sharp, CONTEXT: under what circumstances, SEVERITY: how intense, MODIFYING FACTORS: what makes it worse, ASSOCIATED SYMPTOMS; what else is happening, DURATION: how long,
Created by: Lizbeth Romo