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EvaluationManagement

Evaluation and Management (E/M) services

QuestionAnswer
What are three key components of E/M Services? The three key components--history, examination, and medical decision making.
---appear in 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. The three key components--history, examination, and medical decision making.
What 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.
In the case of visits which consist predominantly of counseling or coordination of care, what is the key or controlling factor to qualify for a particular level of E/M service. Time
What are two subcategories of Office visits? New patient and Established patient
What are the two subcategories of Inpatient visits? Initial and Subsequent
Subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. This classification is important because the nature of work varies by___? Type of service, place of service, and the patient's status.
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 Is listening to body sounds, A stethoscope may be used to listen to the heart and lungs for sounds.
Percussion Is creating sounds from tapping on body areas to examine body organs and body cavities. The vibrations of sounds help identify abnormalities. Lungs sound hollow when percussed.
BP Blood pressure
CC Chief complaint
HEENT Head, eyes, ears, nose, throat
h/o History of
HPI History of present illness
Hx History
NAD No apparent distress
NKDA No known drug allergies
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
The reason the visit was initiated is the primary diagnosis for any ______. E/M Service
The reason for an E/M service 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.
Preventive care E/M codes are typically used with a diagnosis code (s) located in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99). These Z codes are for use in any healthcare setting and may be used as either a first or second code, depending on circum/encounter.
The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service.
Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area. An (ie), newborn records may include under (HPI) the details of mother’s pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family.
The levels of E/M services are based on four types 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).
The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon______. clinical judgment and the nature of the presenting problem(s).
Documentation guidelines are identified by the symbol___. DG
Chief Complaint The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. (DG: The medical record should clearly reflect the chief complaint).
What are the following elements part of: location; quality; severity; duration; timing; context; modifying factors; and associated signs and symptoms. The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.
Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). A brief HPI consists of one to three elements of the HPI. DG: The medical record should describe one to three elements of the present illness (HPI).
Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). An extended HPI consists of four or more elements of the HPI. DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.
Review of Systems (ROS) A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.
For purposes of ROS, the following systems are recognized: Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic
A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.
An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented
A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of
Is there a distinction made to whether you are a new or established patient when you visit the Emergency room? No distinction is made between new and established patients in the emergency department. Evaluation and Management services provided in an Emergency Department are reported with codes from the Emergency Department Services Subsection 99281-99285
What determines the amount of physician work and skill required to evaluate and treat the patient? The extent of the patient's illness or injury will determine the amount of physician work and skill required to evaluate and treat the patient.
"My throat is sore" or "I am having pain in my back," are examples of what type of complaint? A chief complaint the chief complaint is often stated in the patient words.
How would a doctor communicate that a patient was in for a follow up? A simple statement of follow up is not sufficient for a chief complaint. It is necessary for a provider to document the condition being followed up on. Example: follow up visit for ankle pain, or breast pain.
What does the provider use the patients history for? The patient's history is used for the provider to troubleshoot the chief complaint based on an interview with the patient.
History is divided into what three components? History of Present Illness (HPI), Review of Systems (ROS), Past, Family, and Social History (PFSH)
Subsequent Hospital Care Are visits to the patient while the patient is in the hospital. Services include the provider reviewing the medical record, diagnostic test results, and changes in the patient's status since the last physician assessment.
Hospital Services/Inpatient Services/Discharge Services are code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. Codes 1110F-1111F, may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time.
Created by: MissMeeMee