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Cards In This Set
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3 Factors of E/M coding?
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Place of service
Type of Service
Patient Status
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Place of Service- Outpatient vs Inpatient?
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1st Step in correct E/M code.
Identify the place or setting in which the service was provided.
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Type of Service?
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2nd Step in correct E/M coding.
Kind of services - Consultation, Hospital Admission, or an Office Visit.
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Patient Status?
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3rd step in choosing the correct E/M code.
Identify pt. status. New pt., Est. pt., Outpt., Inpt.
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New patient?
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Not received face to face professional services from the Dr. or another Dr. of the same specialty in the same group practice w/in the past 3yrs.
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Established patient?
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Received face to face. . . . w/in the past 3yrs.
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Outpatient?
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Has not been formally admitted to a health care facility.
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Inpatient?
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Has been formally admitted to a health care facility.
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3 Key Components of the service?
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History, examination, and medical decision making complexity
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History (Subjective-Patient Provides) as being the 1st key component what are the 4 elements?
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CC-Chief Complaint
HPI-History of Present Illness
ROS-Review of Systems
PFSH-Past, Family, and Social History
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Reason for the patients encounter/visit in the patients words is called what?
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CC-Chief Complaint. A concise statement describing the symptom, problem, condition, diagnosis, Dr. recommended return or other factor.
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History of Present Illness is another 1 of the 3 key components which means?
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Chronological description of the patients present illness from the 1st sign/symptom or from the previous encounter to the present. (hint:8 elements)
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8 of the elements in the HPI are what?
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Location, Quality, Severity, Duration, Timing, Context, Modifying factors, Associatied signs and symptoms.
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HPI - site on the body? ex. right arm.
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Location
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HPI - Characteristics, such as throbbing, sharp, radiating?
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Quality
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