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Miscellaneous
Evaluation and Management (E/M) services
| Term | Definition |
|---|---|
| The medical record should be complete and legible | |
| Ancillary care refers to the wide range of healthcare services provided to support the work of a primary physician. | These services can be classified into three categories: diagnostic, therapeutic, and custodial. Diagnostic services include laboratory tests, radiology, genetic testing, diagnostic imaging, and more |
| Therapeutic services range from | Therapeutic services range from rehabilitation to physical and occupational therapy, as well as massage, chiropractic services, and speech therapy |
| Custodial services include | Custodial services include everything from hospice care and long-term acute care to nursing facilities and urgent care. |
| ACS Provider | Ancillary Care Services |
| For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient’s status. | The CPT and ICD-9-CM codes reported on the health insurance claim form should be supported by the documentation in the medical record. |
| The three key components of E/M services and for visits which consist predominantly of counseling or coordination of care. | The three key components--history, examination, and medical decision making. |
| Components of E/M services | The descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. |
| DG | Documentation guidelines are identified by the symbol |
| The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. | These components are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. |
| Selecting the level of E/M services | The first three of these components (i.e., history, examination and medical decision making) are the key components in |
| In the case of visits which consist predominantly of counseling or coordination of care, time is | the key or controlling factor to qualify for a particular level of E/Mservice. |
| The levels of E/M services are based on four levels of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). | Each type of history includes some or all of the following elements: Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) and Past, family, and/or social history (PFSH). |
| BP | Blood pressure |
| CC | Chief complaint |
| HEENT | Head, ears, eye, nose, throat |
| h/o | History of |
| HPI | History of present illness |
| Hx | History |
| NAD | No apparent distress |
| PE | Physical examination |
| PERRLA | Pupils equal, round, and reactive to light and accommodation (for example normal) |
| PMH | Past medical history |
| pt | Patient |
| R/O | Rule out |
| ROS | Review of systems |
| WNL | Within normal limits |
| After inspection and observation (visual evaluation), a physician may explore a body system further using | Palpation (refers to examination of the body by touch), auscultation, and percussion. |
| Palpation | Refers to examination of the body by touch. Body parts are palpated to look for organ size or condition (for example, abdominal masses), or for tenderness (for example, there is no tenderness to palpation). |
| Auscultation | Listening to body sounds, a stethoscope may used to listen to the heart and lungs for sounds. |
| Percussion | Creating sounds from tapping on body areas to examine body organs and body cavities. The vibrations of the sounds help identify abnormalities. Lungs sound hollow when percussed. |
| E/M | Services provide physicians with the opportunity to evaluate and manage symptoms, illnesses, and diseases with which their patients present. |
| E/M and diagnosis coding | Diagnosis coding for E/M services is not limited to one section of the ICD-10-CM code book. |
| Primary diagnosis | The reason the visit was initiated is the primary diagnosis for any E/M service. The reason may be a symptom, such as a cough, or a disease, such as diabetes. A visit also may be for preventive care, such as a yearly exam. |
| E/M Service | History, exam, medical decision-making (MDM), counseling, coordination of care, nature of presenting problem, and time. |
Created by:
MissMeeMee
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