Busy. Please wait.
or

show password
Forgot Password?

Don't have an account?  Sign up 
or

Username is available taken
show password

why

Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.

By signing up, I agree to StudyStack's Terms of Service and Privacy Policy.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove ads
Don't know
Know
remaining cards
Save
0:01
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
Retries:
restart all cards




share
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

E/M

E/M coding

QuestionAnswer
E/M codes all begin with what two numbers? 99
What does E/M codes describe or identify? place of service, nature of the presenting problem, time spent of the service, and the content/extent/level of the service.
What does E/M mean? Evaluation and Management
E/M codes are found in what part of the manual? beginning of CPT manual
Where are E/M codes generally found on an encounter form? within the first section to complete
A ______ patient has not received any face -to -face professional services from this physician or another physician of the same specialty at your facility within the last three years. new patient
A _______ patient has received face-to-face professional services from this physician or another physician of the same specialty at your facility within the last three years. established patient
What components must be considered before determining the level of E/M service to report? History, examination, and MDM
How many key components are there - name them Three: History, examination, and MDM
When reporting an outpatient service for a new patient, does the coder need all three key components before reporting the E/M code? All 3 key components are needed for a new patient for outpatient services.
When reporting an outpatient service for an established patient, does the coder need all three key components before reporting the E/M code? The coder only needs 2 of the 3 key components to report an outpatient service for an established patient.
What are the contributing components? Extent of counseling, Coordination of care with others, Nature of presenting problem(s), and Time
What are these? • Key components (KC)1. History2. Examination3. Medical decision making• Contributing components:4. Extent of counseling5. Coordination of care with others6. Nature of presenting problem(s)7. Time seven components for E/M coding
What components are factored in, as applicable?Key Components or Contributing Components? Contributing Components
What are the four elements of History? 1). chief complaint (CC)2). history of present illness (HPI )3). review of systems (ROS)4). past,family,and social history (PFSH)
What is CC? Chief Complaint
What is HPI? History of Present Illness
What is ROS? Review of Systems
What is PFSH? Past Medical, Family and Social History
The ______ includes the symptoms, reason(s) for the visit, stated problem of the patient, signs, and diagnosis (if any were established prior to the visit). CC - Chief Complaint
What are the eight elements of HPI? location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
HPI is based on the number of elements. It can be either _______ HPI or _____ HPI. Brief or Extended
If the report has 4-8 elements, it will be an ______ HPI Extended
If the report has 1-3 elements, it will be a _____ HPI. Brief
Concerning HPI, what are these an example of: hand, head, foot, etc.. This is 1 of the 8 elements of HPI location of the symptom
Concerning HPI, what are these an example of: burning, fullness. This is 1 of the 8 elements of HPI. quality
Concerning HPI, what are these examples of: mild, intense, horrible; some may use a scale to decide this, such as "on a scale from 1-10, how would you rate your pain" This is 1 of the 8 elements of HPI serverity
Concerning HPI, what is this an example of: "since last month" "since two days ago" This is 1 of the 8 elements of HPI and it explains how long the patient suffered. Duration
Concerning HPI, what is this an example of: "after eating, after exercise"This is 1 of the 8 elements of HPI. timing
Concerning HPI, what is this an example of: "when slumping," "only when sitting," "while running" This is 1 of the 8 elements of HPI and it identifies symptoms associated with a situation. Context
Concerning HPI, what is this an example of: "sitting up straight," "cold compress" This is 1 of the 8 elements of HPI and it identifies the factors that make the condition better, or worse. Modifying factors
Concerning HPI, what are these examples of: "hard to swallow, chest pain" This is 1 of the 8 elements of HPI and it tells of the problems that happen at the same time as another problem. associated signs and symptoms
A _______ _________ ROS is a review of the one body system that is directly related to the chief complaint or presenting problem. Problem pertinent
An ________ ROS is a review up to 9 additional systems Extended
A ________ ROS is a review of 10 or more body systems Complete
________ is the inventory of the body systems ROS
The number of systems reviewed and documented determines the _____ of ROS selected. level
What is OS? Organ System
What is BA? Body Area
How many levels are there of PFSH? 2: Pertinent and Complete
For a PFSH to be Pertinent, it must have how many items from the past? 1 item from the past
For a PFSH to be Complete, it must have how many items from the past for an established patient? 2 items from 2 areas
For a PFSH to be Complete, it must have how many items from the past for a new patient? 3 items out of 3 areas
For a Complete PFSH, does it matter if the patient is new or established concerning how many items from the past should be obtained? yes
What are elements of Past and Social History Major illnesses/injuriesOperations HospitalizationsAllergiesImmunizationsDietary statusSexual historyOther relevant social factors
Are the types of History and the types of Examination the same? yes
What are the types of History and Examination? 1. Problem focused2. Detailed3. Expanded problem focused4. Comprehensive
Who developed the E/M Coding Guidelines? AMA & CMS
Sometimes the case may mostly consist of counseling or coordination of care. What factor would the coder use to code this service? Time
What must support the code selection? Documentation
If the physician focuses on the CC, and a breif history of the present problem, what type of history is it? problem focused history
If the physician centers his attention on the CC, obtains brief history of present problem, performs a problem pertinent ROS, what type of history is it? expanded problem focused history
If the physician focuses on the CC, obtains an extended history of present problem, an extended ROS, and a pertinent PFSH, what type of history is it? detailed history
If the physician documents the CC, does an extended history of present problem, complete ROS, and complete PFSH, what type of history is is? This is the most complex history type. comprehensive history
If the exam is limited to the affected BA, or OS, identified in CC, what type of exam is it? problem focused exam
If the exam is limited, made of affected BA or OS, and other symptomatic or related BA's / OS's, what type of exam is it? expanded problem focused exam
If it is an extended exam concerning the affected BA, and other symptomatic or related OS, what type of exam is it? detailed exam
If the exam is extensive, consists of a complete single-specialty exam or complete multisystem exam, what type of exam is is? This is the most complex exam. comprehensive exam
What is the first visit? initial
What is the second visit? subsequent
When selecting a history level, the coder should select the ______ level. lowest
What are the medical decision making complexity levels? Straightforward decision makingLow-complexity decision making,Moderate decision making,High-complexity decision making
When selecting the MDM level, the coder will select the ______. In other words, select the level of the higest two. majority
What is MDM based on? the number of diagnoses or management options. The amount or complexity of data to review. The risks of complication or death if the condition goes untreated
What type of MDM is this: * minimal diagnosis and management* data and complexity are minimal/none* minimal risk straightforward decision making
What type of MDM is this:* limited # of diagnoses & management* limited data* low risk low-complexity decision making
What type of MDM is this:* multipul diagnoses & management * moderate complexity & data* moderate risk moderate-complexity decision making
What type of MDM is this:* extensive diagnoses & management* extensive complexity & data* high risk high-complexity decision making
Created by: CTUGirl