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Evaluation & Managem

Evaluation & Management

QuestionAnswer
Which element of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days. Location, quality and duration
A physician admits a pt to the hospital . They are there for 5 days & the physician sees them each day in the hospital. What subcategory of codes would be used for days two, three, and four? Subsequent hospital care
If the pain is sharp stabbing or dull, what is the component of the HPI? Quality
Where are clinical examples for evaluation and management codes found in the CPT? Appendix C
A pt presents to a cardiologist for an initial visit at the request of his pcp to treat CHF. The cardiologist exams the pt and discusses treatment options and schedule the pt for a stress test. An E/M code would be selected from what subcategory? New pt office visit.
According to the CPT guidelines, what is the first step in selecting an E/M code? Determining the category or subcategory
What category of codes should be used to report an E/M service provided to a pt in a psychiatric residential treatment center ? Nursing facility services
A pt is fishing and gets light headed and dizzy. He goes to the local hospital ED and evaluated by the ED physician. This is the fist time he has been to this hospital. What subsection would be used to report the ED visit? Emergency department services
A pt is seen by Dr. B, who is covering on call services for Dr. A. The pt is an established pt with Dr. A, but has never been seen by Dr. B before. What is the appropriate E/M subcategory to report for services by Dr. B? Established pt office visit
What modifier would be used to report an E/M service mandated by a court order. Modifier 32
When tissue glue is used to close a wound involving the epidermis layer how is it reported? As thought it was a simple closure.
P1 A normal healthy patient
P2 A patient with mild systemic disease.
P3 A patient with a severe systemic disease.
P4 A patient with a severe systemic disease that is a constant threat to life.
P5 A moribund patient that is not expected to survive without the operation.
P6 A declared brain dead patient whose organs are being removed for donor purposes.
Palpation Refers to examination of the body by touch.
Auscultation Listening to body sounds.
Percussion Creating sounds from tapping on body areas to examine body organs and cavities. the vibrations of the sounds help identify abnormalities. (lungs sound hollow when percussed.)
Stethoscope May be used to listen to the heart and lungs for sounds.
BP Blood pressure
CC chief complaint
HEENT Head, eyes, ears, nose and throat
h/o history of
HPI history of present illness
E/M services are used to...what Used to "evaluate and manage" all symptoms, illnesses, and diseases.
The primary diagnosis for E/M is ... the reason the visit was initiated. It can be a symptom ( such as a cough or disease), or for preventative care (V code needed).
Is diagnosis for acute, chronic or an acute phase of a chronic condition? When the condition is an acute phase of a chronic condition and there is a code to describe each of the phases, list the acute code first and the chronic second. Be aware of combination codes, such as "acute and chronic cholecystitis."
When a patient with multiple conditions is seen.. ..only those conditions affecting care, or requiring provider care or management, are coded.
E/M codes describe .... a provider's service to a patient including evaluating the patient's condition(s) and determining the management of care required to treat the patient.
What are the 3 key components of E/M History, Exam, and MDM ( medical decision making)
What is medical necessity It is what is necessary to treat the patient for a given condition/complaint.
Created by: mpittman
 

 



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