Chapter 15 E/M

5 types Nature of presenting problem
1. Minimal
2. Self-limited or minor
3. Low severity
4. Moderate Severity
5. High Severity
Does not require physician
Self-limited or minor
Problem that runs a definite course, has good prognosis
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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
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
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
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
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
History: comprehensive
HPI= extended
ROS= Complete
PFSH= complete
History: Detailed
HPI= Extended
ROS= Extended
PFSH= Pertinent
History: problem focused
HPI= Brief
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:
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.
Expanded problem focused
What are the four levels of medical decision making complexity?
Low Complexity High Complexity Moderate Complexity Straightforward
The code range for Home Services is ________.
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
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
An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity
The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?
Expanded problem focused
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.
Any of above
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:
Gender and age
Length of time elapsed since last exam
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 ________.
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.
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:


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:


LOCATION: Inpatient, Hospital

PATIENT: Mandy Horton


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:


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