5 types Nature of presenting problem
1. Minimal 2. Self-limited or minor 3. Low severity 4. Moderate Severity 5. High Severity
Minimal
Does not require physician
Self-limited or minor
Problem that runs a definite course, has good prognosis
Low severity
Risk of morbidity w/o treatment is low. recovery w/o funcional impairment
Moderate severity
Risk of morbidity w/o treatment is moderate, uncertain prognosis
High severity
Risk of morbidity w/o treatment is high to extreme, high probability of svere, prolonged functional impairment.
Key components
1. History 2. Examination 3.Medical Decision making
Complete PFSH (established)
1 specific item from 2 of the 3 history areas. For services: office or other outpatient- established ED Subsequent Nursing facility Domiciliary care- established Home care- established
Complete PFSH ( new Patient)
1 Specific item from each of the 3 history For Services: office of other outpatient-new pt hospital obs. hopital inpt-initial care consultations comprehensive nersing assessment domiciliary care-new pt home care- new pt
7 Components Recognized
1. history 2. Examination 3. Medical Decision making 4. Couseling 5. Coordinatio of care 6. nature of presenting probelm 7. time
Perinent PFSH
1 specific item from any 3 history
Externded ROS
2-9 systems reviewed w/ positive and or negative
Complete ROS
At least 10 must be reviewed system w/ positive or negative must be individually documented
ROS
1. Constitutional symptoms (fever, weight loss) 2. Eyes 3. Ears, nose, mouth, throat 4. cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. integumentary 10. Neurological 11.Psychiatric 12. Endocrine 13. Hematologic/ lymphatic 14. Allergic/ immunologic
Extended HPI
4 or more HPI or associated comorbidities or status of 3 or more multiple chronic conditions
HPI Elements
1. location 2. quality 3. severity 4. duration 5. timing 6. context 7. modifiying factors 8. associated sign and symptoms
Brief HPI
3 Elements of HPI
History: expeanded problem focused
HPI= Brief ROS= Problem pertinent PFSH= N/a
History: comprehensive
HPI= extended ROS= Complete PFSH= complete
History: Detailed
HPI= Extended ROS= Extended PFSH= Pertinent
History: problem focused
HPI= Brief ROS= N/A PFSH= N/A
straightforward
all minimal
low complexity
# of DX=limited Data reviewed= limited Risk of complications= low
moderate complexity
# of Dx= multiple Data reviewed= moderate Risk of complications= moderate
High complexity
# of Dx= extensive data reviewed= extensive Risk of complications= high
4. The level of E/M service is based on: Documentation Key components Contributing factors All of the above
all of the above
According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam. Problem-focused Expanded problem focused Detailed Comprehensive
Comprehensive
What are the four levels of medical decision making complexity?
Low Complexity High Complexity Moderate Complexity Straightforward
The code range for Home Services is ________.
99341-99350
What are the four levels of history type?
problem-focused, expanded problem-focused, detailed, comprehensive
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?99284 99291 99283 99220
99284
Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused Expanded problem focused Detailed Comprehensive
detailed
An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity
99253
The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination? Problem-focused Expanded problem focused Detailed Comprehensive
detailed
Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
99291, 99292
Counseling, coordination of care, nature of presenting problem, and time are considered: Levels of E/M service Key components Contributory factors Medical decision-making process
Contributory factors
These elements would be part of the ________ history: employment, education, use of drugs. Past Social Family Any of above
Social
The HPI must be documented in the medical record by: The physician Any office staff member The patient Any of the above
The physician
When a physician performs a preventive care service, the extent of the exam is determined by the: Age Gender Gender and age Length of time elapsed since last exam
Age
The definition of low birth weight can be found in the notes for subheading ________.
Continuing intensive care
The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.
outpatient
The ________ is a statement describing the reason for the encounter and is a history element.
Chief Complaint
Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.
-25
Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward. CPT Code:
99341
CHART NOTE CC: Dizziness SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49. OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9. ASSESSMENT: Hypothyroidism (MDM was low). PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months. CPT Code:
99213
CAPD CYCLER DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Mandy Horton ATTENDING PHYSICIAN: Ronald Green, MD This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out. The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.) CPT Code:
99232