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Miscellaneous

Evaluation and Management (E/M) services

TermDefinition
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