The Next Step- Chapter 1 – Flashcards
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What are three factors of E/M codes?
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Place of service, type of service, and patient status.
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Place or setting in which the service was provided is called?
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Place of service
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There are different codes for outpatient and inpatient settings.
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True
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Kind of service provided is called?
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Type of service
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Codes are divides based on the types of service.
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True
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How many types of patients statuses are there?
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four
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Has not received professional services from the physician or another physician of the same specialty and sub specialty in the same group practice within the past 3 years.
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New patient
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has received professional services from the physician or another physician of the exact same specialty and sub specialty in the same group practice within the past 3 years.
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Established patient
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Has not been formally admitted to a health care facility.
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Outpatient
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Has been formally admitted to a health care facility.
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Inpatient
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The three key components are the history, examination,and a medical decision-making complexity.
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True
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Is the subjective (patient provided) information that the physician elicits regarding to the chief complaint
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History
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There are four elements of history.
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True
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What are the four elements of history?
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Chief Complaint(CC), History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and Social History (PFSH)
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CC
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Chief Complaint
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HPI
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History of Present Illness
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ROS
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Review of Systems
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PFSH
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Past,Family, and Social History
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A concise statement describing the symptom,problem,condition,diagnosis,physician recommended return or other reason for the encounter/ visit usually in patient's words is called a
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chief complaint
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Is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present
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History of Present Illness
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Location means
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Site on the body
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Quality means
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Characteristics, such as throbbing, sharp
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Severity means
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How intense or on a scale of 1/10
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Duration means
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How long for this problem or episode
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Timing means
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When does it occur
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Context means
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Under what circumstances does it occur
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Modifying factors means
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What makes it better or worse
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Associated signs and symptoms means
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what else is happening when it occurs
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The extent of the HPI as problem focused, expanded problem focused, detailed, or comprehensive is based on the physician's professional judgement depending on the needs of the patient.
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True
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What are the two levels of HPI
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Brief (1-3 elements) and extended(4 or more elements)
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The problem-focused and expanded problem-focused levels of history contain a brief review of the problems surrounding why the patient is being seen that day.
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True
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The detailed and comprehensive levels of history contain an extended review of the HPI elements.
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True
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An inventory of the body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced.
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Review of Systems
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A review of the patient's past experience with illnesses, injuries, and treatment .
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Past History
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A review of medical events in the patient's family
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Family History
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An age appropriate review of past and current activities
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Social History
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is a review that is focused on the organ system involved in the chief complaint
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Problem pertinent ROS
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Includes a review of the system directly involved in the chief complaint, plus related (up to nine) systems.
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Extended ROS
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Includes at least 10 of the 14 Organ Systems
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Complete ROS
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is a review of the pas, family,and social history of the patient
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PFSH
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What are the two levels of PFSH?
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pertinent and complete
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What are the four levels of history?
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problem focused, expanded problem focused, detailed, and comprehensive
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When the physician focuses on the CC and a brief history of the present problem of a patient.
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Problem focused
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When the physician focuses on a CC, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.
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Expanded problem focused
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When the physician focuses on a CC and obtains an extended history of the present problem.
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Detailed
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When the physician documents the CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH
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Comprehensive
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Is the subjective information the patient provides the physician
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History
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Objective information that the physician gathers.
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Examination
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Head (Including face)
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Body Area
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Neck
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Body Area
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Chest (Including Breast and axillae)
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Body area
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Abdomen
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Body Area
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Genitalia, groin,and buttocks
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Body Area
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Back
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Body Area
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Each extremity
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Body Area
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Ophthalmologic (eyes)
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Organ System
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Otolaryngologic (ears,nose,mouth, and throat)
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Organ System
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Cardiovascular
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Organ System
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Respiratory
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Organ System
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Gastrointestinal
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Organ System
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Genitourinary
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Organ System
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Muscoskeletal
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Organ System
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Integumentary (Skin)
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Organ System
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Neurologic
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Organ System
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Psychiatric
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Organ System
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Hematologic/ Lymphatic/ Immunologic
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Organ System
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What are the four levels of examination?
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Problem focused,expanded problem focused, detailed, and comprehensive
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Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA
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Problem Focused
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A limited examination of the affected area BA or OS and other related BAs or OSs. It involves a limited examination of 2-7 BAs or OSs
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Expanded problem focused
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An extended examination of the affected BAs or related OSs. It involves an extended examination of 2-7 BAs or OSs
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Detailed
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Encompasses at least 8 OSs without counting BAs
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Comprehensive
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The levels of examination include both body areas (BA) and organ systems (OS), with the exception of the comprehensive examination.
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True or False
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When abstracting a medical record count both the
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BAs and OSs`
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Constitutional on the exam count as 1 OS and that OS counts when calculating the examination.
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True or False?
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the key component of MDM is based on the__________ of the decision the physician must make regarding the patient's diagnosis and care.
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complexity
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Complexity of decision making is based on three elements.
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True or False?
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What are the three elements of decision making?
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number of diagnoses or management options, Amount and/or complexity of data to review, and risk of complication and/or death if the condition goes untreated.
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What are the four types of MDM complexity?
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straightforward, low, moderate,and high
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Blood pressure, sitting
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Constitutional(OS)
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Blood pressure, lying
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Constitutional(OS)
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Pulse
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Constitutional(OS)
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Respiration
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Constitutional(OS)
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Temperature
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Constitutional(OS)
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Height
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Constitutional(OS)
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Weight
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Constitutional(OS)
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General appearance
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Constitutional(OS)
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Minimal diagnosis and/or management options, minimal or none for the amount and complexity of data to be reviewed,and minimal risks to the patient of complications or death if untreated.
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Straightforward
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Limited number of diagnosis and/or management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated
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low complexity
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multiple diagnosis and or management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.
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moderate complexity
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extensive diagnosis and or management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.
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high complexity
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____________ factors are those conditions that help the physician to determine the extent of history, examination, and decision making necessary to treat the patient
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Contributory
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What are the three contributory factors?
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counseling, coordination of care, and the nature of the presenting problem.
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Involves discussion of diagnostic results, impressions, and recommended diagnostic studies; prognosis; risks and benefits of treatment;instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education.
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Counseling
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A physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long- term nursing facility.
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Coordination of care
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a disease, conditon, illness, injury, symptom, sign finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter
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Presenting problem
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How many types of presenting problems are there?
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five
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What are the five types of presenting problems?
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Minimal, Self-limited, low severity, and moderate severity
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A _______ problem is a blood pressure reading, a dressing change,or another service that can be performed without the physician being immediately present.
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Minimal
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also called a minor presenting problem
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self-limited
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The risk of complete sickness without treatment is low, there is no risk of death without treatment, and full recovery without impairment is expected.
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low severity
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the risk of complete sickness without treatment is moderate, there is moderate risk of death without treatment and an uncertain prognosis or increased probability of impairment exists,
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moderate severity
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The risk of complete sickness without treatment is high to extreme, there is a moderate to high risk of death without treatment, or there is a strong probability of severe, prolonged functional impairment.
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High severity
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What are two measurements of time?
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Face-to-face time and unit/floor time
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_________ time is the time a physician spends directly with a patient during an office visit obtaining the history, performing an examination, and discussing results.
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Face-to-Face time
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Inpatient time is measured as ________ time and is used to describe the time a physician spends in the hospital setting dealing with the patient's care.
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unit/floor time
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_______ services are based on time
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Discharge
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More than one physician can use the subsequent care codes on the same day. This is called
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Concurrent Care
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Who maintains the primary responsibility for the overall care of the patient,no matter how many other physicians are providing services to the patient, unless a formal transfer of care has occurred.
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attending physician
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These codes are reported for either inpatients or outpatients who are admitted and discharged on the same day.
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Observation or Inpatient Care Services (99234-99236)
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______________ are reported on the final day of services for a multiple-day-stay in a hospital setting.
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Inpatient Hospital Discharge Services
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Findings that were not the reason for the test.
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Incidental findings
