PC: Ch. 3 – Evaluation & Management

PC: Ch. 3 – Evaluation & Management

brief HPI
consists of one to three elements of the history of the presenting illness (HPI)
care plan oversight
a service billed once a month, which includes all care rendered to a patient over a 30-day period of time
case management
a service provided by an attending physician in which the physician not only supervises but coordinates direct care received by a patient
chief complaint (CC)
the reason for the patient encounter
complete PFSH
review of two or all three of the past, family, and/or social history areas
comprehensive examination
highest level of examination and consists of a multisystem examination or complete examination of a single organ system
comprehensive history
documentation of four or more elements of the history of presenting illness (HPI), a complete review of systems (ROS), and a complete PFSH; perform all elements identified by a bullet in at least 9 organ systems or body areas and document at least 2 elements by a bullet from each of the 9 areas/systems
contributory components
factors that contribute to the selection of E/M codes: counseling, coordination of care, and nature of the presenting problem
consultation
services rendered by a provider when his or her opinion or expertise is requested by another provider or appropriate source; distinguish a consult by the presence of the 3 Rs; the provider receives a Request to Render an opinion and in doing do are Responding to the request.
critical care
a patient who requires constant attention by the provider due to situations related to the patient’s medical condition and whose illness or injuries would put the patient at high risk should he or she not get this constant attention
detailed examination
examination of affected area, but also other systems or related organs
detailed history
four or more elements of the HPI, a ROS of 2-9 systems, and an element from the PFSH related to the patient’s problem; at least 2 elements identified by a bullet from each of 6 areas/systems or at least 12 elements identified by a bullet in 2 or more areas/symptoms
elements of examination
system or body area that was examined by the provider
Emergency Department (ED)
a hospital-based facility that provides episodic services to patients who present for immediate medical attention
established patient
a patient who has received professional services from a physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years
evaluation and management (E/M)
section in CPT that is used to report the evaluation of a patient’s condition and then the management or care plan for the condition
expanded problem-focused examination
where the affected area is examined along with other body systems or areas that might also be affected by the problem that brought the patient to the office; at least 6 elements identified by a bullet
expanded problem-focused history
one to three elements of the history of the present illness as well as a review of systems directly related to the chief complaint
extended HPI
consists of at least four elements of the history of presenting illness (HPI)
face-to-face time
used for office and other outpatient visits and consultations; the time a physician spends face-to-face with the patient and or family
family history
information regarding immediate family members who suffer from a chronic or acute illness that would impact the care of the patient
high-complexity medical decision-making
medical decision-making of a higher or more complex level
history
history of present illness, review of systems, and past, family, and social history make up the complete patient history
history of present illness (HPI)
a chronological description of the patient’s present illness
initial observation care
the initial care for patients who are seen for evaluation and management services during observation
low birth weight (LBW)
an infant with present body weight of 1,500 to 2,500 grams
low-complexity medical decision making
involves medical decision-making that is of low risk to the patient
moderate-complexity medical decision making
higher level of elements and more complex combination of risk factors that need to be decided on
nature of the presenting problem
the severity of the presenting problem; five types of presenting problems are present in CPT
new patient
a patient who has not received professional services from a physician or another physician of the same specialty who belongs to the same group practice within 3 years
observation / observation status
where the patient is in the hospital for a short time to determine the course of action
past, family, and/or social history (PFSH)
the last portion of the history of the present illness; consists of past, family and social history of the patient
past history
any past medical information that may impact the medical decision-making process
pertinent PFSH
a review of the history area related to the problem identified in the HPI
physician standby services
physician requests another physician to stand by in the event the first physician’s services are needed
place of service (POS)
a code number used to convey the place where the patient received care or service
preventive medicine services
services provided to a patient who is presenting to a medical office for a “well visit” or a physical examination that includes a routine checkup, annual gynecological examination, or other examinations whose focus is promoting health
problem-focused history
a brief history of present illness that is related to the problem that brought the patient to the office; 1 – 5 elements identified by a bullet
psychiatric residential treatment center
treatment center that provides 24-hour care that includes a therapeutically planned and professionally staffed group living and learning environment with physician assessment and care plans
revenue
the amount of money a practice will make
review of systems (ROS)
an inventory of body systems that is obtained from the patient to identify signs and symptoms that the patient may be experiencing or has experienced
SOAP note
provider note that contains the
subjective (HPI/ROS/PFSH),
objective (exam),
assessment (diagnosis), and
plan (medical decision making)
of a patient encounter
social history
part of the HPI that discusses the patient’s marital status; use of tobacco, alcohol, drugs; and other social factors that would impact patient care
straightforward medical decision-making
medical decision-making that is of low or straightforward risk
unit / floor time
used for hospital observation services, inpatient hospital care, initial and follow-up hospital consultations and nursing facilities; time includes when the provider is present on the patient’s unit and at the bedside rendering services
very low birth weight (VLBW)
weight of an infant less than 1,500 grams
evaluation and management coding
Three major questions must be asked when identifying an E/M code:

1) Is the patient new or established?
2) Where is the service provided?
3) What is the degree of the service rendered?

level of service
Seven components go into making up levels of service for E/M codes. The first three are considered key components; the rest are considered contributory components.

1) history
2) examination
3) medical decision making

4) counseling
5) coordination of care
6) nature of presenting problem
7) time

level of service
history
Four types of history:
1) problem focused
2) expanded problem focused
3) detailed
4) comprehensive
types of history
1) chief complaint (CC)
2) history of presenting illness (HPI)
3) review of systems (ROS)
4) past, family, and social history (PFSH)
levels of examination
• Problem Focused: 1 – 5 elements
• Expanded Problem Focused: 6+ elements
• Detailed: 2 elements from 6 areas/systems or 12+ from 2+ body systems
• Comprehensive: all elements from 9 areas/systems and document 2 elements from each of 9 areas/systems
medical decision making
There are 4 levels of medical decision making:
• straightforward
• low complexity
• moderate complexity
• high complexity

The type of medical decision making is based on 3 factors:
• The number of diagnoses or management options
• The amount and/or complexity of data to be reviewed
• The risk of complications and/or morbidity or mortality

number of diagnoses or management options
The value of terms is approximate the number of diagnoses or management options:
• minimal – at least 1
• limited – at least 1
• multiple – at least 2
• extensive – at least 2
amount and/or complexity of data to be reviewed
Five, nonstandardized terms are used to describe the level of data reviewed:
• none
• minimal
• limited
• moderate
• extensive
risk of significant complications, morbidity, and/or mortality
nursing facility services
Includes:
skilled nursing facilities (SNF)
long term care facilities (LTCF)
intermediate care facilities (ICF)
convalescent care
rehabilitative care
psychiatric residential treatment center
nursing facility assessments
A resident assessment instrument (RAI) includes the
Minimum Data Set (MDS), Resident Assessment Protocols (RAPs) and utilization guidelines.