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Bill 11
| Question | Answer |
|---|---|
| Where is the place of service? | explains the setting in which the services were provided to the patient. office, hospital, /ER dept, nursing home. |
| What is the type of service? | is the reason the service is requested or performed examples of types of service are consultation, admission, newborn care, and office visit. |
| TOS: Consultation | is a written or verbal request from one provider/physician to another to obtain an opinion and or advice about a diagnosi or management options. |
| TOS: Admission | is attention to an acute illness or injury that results in admission to a hospital. |
| TOS: Newborn Care: | is the evaluation and determination of care management of a newly born infant. |
| TOS: Office Visit | is a face-to-face encounter between a physician and a patient to allow for primary management of the patient's health care status. |
| What is Patient Status? | 4 types of pt status are new pt, established pt, outpatien and inpatient codes are often grouped in the CPT manual according to the type of patien involved |
| Pt Status New | is one who has not received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years. |
| Pt Status Established | pt is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years. |
| PT Status Outpatient | is one who has not been formally admitted to a health care facility or a pt admitted for observation. |
| PT Status Inpatient | Is one who has been formally admitted to a health care facility. |
| Medical Decision Making MDM | the number and complexity of problems addressed, amt and or complexity of data reviewed, and risk of complications and/or morbidity or mortality of pt management |
| Time may be used to report | office or other outpt services instead of MDM. Total time is used to report the code. |
| Total time includes | face to face time as well as non face to face time spent on the dos with the pt and performing other activities such as previsit reviewing and charting. |
| Time includes 1): | Preparing to see the patient ie review tests |
| Time includes: 2) | Obtaining and/or reviewing separately obtained history |
| Time includes 3) | Performing a medically appropriate exam and/or evaluation |
| Time includes 4): | Counseling and education the patient/family/caregiver |
| Time includes 5) | Ordering Medications, tests or procedures |
| Time: includes 6 | Referring and communicating with other health care professionals (when not separately reported) |
| Time includes 7 | Documenting clinical information in the electronic or other health record. |
| Time includes 8 | Independantly interpreting results (not separately reported) and communication results to the patient/family/caregiver |
| Time includes 9 | Care cofordination (not separately reported) |
| Prolonged Service codes 99417, 99418, G2212 are only reported when | Level 5 codes are selected on the basis of time alone. One unit of service reports a full 15 min of additional time |
| When clinical staff performs the faced to face time with the patient and the physician or other qualified health care professional performs only supervision report | 99211 when clinical staff performs the face to face time with the pt and the physician or other qualified health care professional performs only supervision. |
| The levels of E/M service are based on | documentation located in the patient's medical record supporting various amts of skill, effort, time , responsiblity, and medical knowledge used by the physician to provide the service to the pt. |
| Selection of an E/M level of service is based on | the level of medical decision making MDM ort total time spent on the dat of the encounter. |
| Medical Decision making the key component of medical decision making reflects the clinical info that is recorded by the dr in the pts | medical record |
| MDM is present in every patient case except for | counseling encounters |
| History and exam are no longer considered key components for these codes but are considered | medically appropriated for counseling codes? |
| Medical Decision Making is base on | the complexity of the decision the physician must make about the pts diagnosis and care |
| MDM complexity of decision making is based on 3 elements | 1.)Number of diagnosis, 2.)Amount and/or complexity of data to review. the data can be minimal,none, limited, moderate, or extensive.3) Risk of complication or death if cond goes untreated |
| Risk can be | Minimal, low, moderate, or high |
| Levels the extent to which each MDM elements determines the | level of Medical decision making complexity |
| Medical Decision making complexity levels 4: | Straightforward, Low, Moderate, High |
| 1)Straightforward decision making | Minimal diagnosis and management options, minimal or none for the amt and complexity of data to be reviewd, and minimal risk to the pt of complications or dath if untreated |
| 2)Low-complexity decision making | Limited number of diagnosis and management options, limited data to be reviewed, and low risk to the pt of complications or death if untreated |
| 3) Moderate complexity decision making | Multiple diagnoses and management options, moderated amt and complexity of data to be reviewed, and moderate risk to the pt of complications or death if untreated. |
| 4) High compolexity decision making | Extensive diagnoses and management options, extensive amt oan complexity of data to be reviewed, and high risk to the pt for complications or death if the problem is untreated. |
| Number and Complexity of Problems. For each encounter, an | assessment, clinical impression, or diagnosis should be documented. It may be stated, ori mplied in documented decisions regarding management plans or futher evaluations |
| Number & Complexity of Problems For a presenting problem with and established diagnosis the record should reflect | whether the problem is: A/ improved, well controlled, resolving, or resolved; or B inadequately controlled, worsening, or failing to change as expected |
| Number & Complexity of Problems For a presenting problem without an established diagnosis | the assessment or clinical impression may be stated in the form of differential dx or as a possible, probable or rule out R/O dx |
| Number & Complexity of Problems Note: Physician/Provider coders do not code | "Rule out", "Possible", or "Probable" diagnosis; reather they code the presenting symptoms and/or complaints unless there is a definitive diagnosis rendered |
| Note Physician/Provider coders code | they code the presenting symptoms and/or complaints unless there is a definitive diagnosis rendered. |
| Number & Complexity of Problems The initiation of, or changes in, treatment should be | documented |
| Number & Complexity of Problems Treatment includes a wide range of management options including: | pt instructions, nursing intsructions, therapies and medications. |
| Number & Complexity of Problems If referrals are made, consultations requested, or advice sought The record should indicate | to whom or where the referral or consultation has benn made or from whom the advice is requested. |
| Data to Be Reviewed and Analyzed basic documentation guidelines for the amt and complexity of data to be reviewed 1 if a dx service is ordered, planned scheduled | at the time of the e/m encounter, the TOS ie lab or radiology should be documented |
| Data to Be Reviewed and Analyzed basic documentation 2 The review of lab rad or other dx test should be | documentewd an entry in progress note such as WBC elevated or chest x-ray neg is acceptable. Alternatively the review may be documented by inital and dating the report containing results |
| Data to be Reviewed and Analyzed basic document 3 A decision to obtain old records or obtain add hx from the | family, caregiver or other source to supplement that obtained from the pt should be documented |
| Data to be Reviewed and Analyzed basic documenta 4 Relevant findings from the review of old records or the receipt of | additional history from the family, caregiver, or other source should be documented |
| Data to be Reviewed and Analyzed basic document 4 continu If there is no relevant info beyond that already obtained, | that fact should be documented. a notation of old records reviewed or additional hx obtained from fam without elaboration is insufficient |
| Data to Be Reviewed and Analyzed basic documenta 5 The results of discussion of lab, rad, or other dx tests with | the physician who performed or interpreted the study should be documented |
| Data to Be Reviewed and Analyazed basic documnat 6 The direct visualization and independent interpretation of an | image, tracing, or specimen previously interpreted by another physician should be documented. |
| Risk some basic documentation guidelines of risk of significant complications morbidity or mortality include | 1. Comorbidities 2ndary conditions, 2If surgical or invasive dx procedure is ordered , 3If a surg or invasive dx procedure is performed at the time of the e/m encounter proced should be documented 4 The ref or dec to perf a surg or inv dx proce urgent |
| Risk Minimal Level 1 | One self-limited or minor problem ie insect bite, tinea corporis |
| Risk Low Level 2 | Two or more self-limited or minor problems One stable chronic illness ie well controlled hypertension or noninsulin dependent diabetes, cataract, benign prostatic hypertrophy |
| Risk Moderate Level 3 | One or more chronic illnesses with mild exacerbation, progresssion, or side effects of treatment two or more stable undx new probl with uncertain prognosis Acute ill with systemic symptoms ie pyelonephritis, pneumonitis, colits |
| Risk High Level 4 | One or more chronic illnesses with sever exacerbation, progression, or side effects of tx , Acute or Chronic illness or inj that pose a threat to life or body funct |
Created by:
luci2