what are the 3 factors of E/M codes
- place of service
- type of service
- patient status
- place of service includes
physician’s office, hospital, emergency department, nursing home, and so on
- types of service includes
reason the service is requested or performed,
consultation, admission, newborn care, office visit
consultation
writtten or verbal request from one provider/physician to another
admission
attention to an acute illness or injury that results in admission to a hospital
newborn care
evaluation and determination oc care management
office visit
face-to-face encounter b/t a physician and a patient to allow primary management
- patient status includes
new, established, outpatient, inpatient
new pt
one who has not received professional services in the past 3 years
established
one who has received professional services from a physician in the sam group within the past 3 years
outpatient
one who has not been formally admitted to a health care facility or a pt admitted for observation
inpatient
one who has been formally admitted to a health care facility
medical record documentation has many uses which are
evaluation of the pts treatment, communications regarding the pts health care, reimbursement claims, review of the use of the health care facility, research/education, and legal documentation
7 organizations developed minimum documentation guidelines are
- american health information management association
- american medical peer review association
- BCBS association
- american hospital association
- managed care and review association
- american medical association
- health insurance association of america
guidelines are as follows
- medical record should be complete and legible
- doc. should include date, reason for encounter, h&p, review of ancillary services, assessment, and plan of care, drs. signature and date
- past and present dx
- reasons for results of x-rays, lab, and other ancillary service
- relevant risk factors-identifed
- pts progress and response to treatment, change in treatment or dx, and any noncompliance should be doc.
- written plan of treatment
- report the intensity of the pt evaluation and/or the treatment including thought processess and complexity of the medical decision making.
- entries should be dated and authenticated by provider or provider extender
- cpt and icd-10 codes reported on the insurance claim or billing statement should reflect the documentation in the medical record
levels of e/m service are (2)
key components and contributory factors
key components
history, exam and medical decision making complexity
contributory factors
counseling, coordination of care, nature of presenting problem, and time
(99214) office or other out pt visit for e/m of an established pt requires at least 2 of 3 key components are
- detailed hx
- detailed exam
- medical decision making of moderate complexity
history
subjective information the pt tells the physician based on the 4 elements of a hx
4 elements of a hx are
chief complaint (cc)
history of present illness (hpi)
review of systems (ros)
past, family, and/or social hx (pfsh)
T/F some history elements may be documented by ancillary staff or the patient
F - ancillary staff are allowed to document some of the hx, such as cc and pfsh, but the physician must authenticate the entries
(CC) chief complaint
concise statement describing the symptom, problem, condition, dx, physician-recommended return, or other factor that is is the reason for the encounter, stated in the pts words
(HPI) history of present illness
chronological description of the development of the pts present illness from the first sign/symptom or from the previous encounter to the present
