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8 Cards in this Set
- Front
- Back
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99201
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level of visit requires three key
components, which are a problem-focused history, a problem focused exam, and a straightforward medical decision-making. It also shows the typical amount of face-to-face time the provider will have with the patient. In this case, it is 10 minutes. |
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observation status
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Use observation discharge if if the discharge is on a date other than the date the patient was initially put in observation status
when observation status is initiated in the course of another service, all of those services are included in that observation status. e.g. if Dr sees a pt in ED and admits him for observation the ED services are not reportable. He would use initial observation care code. * cannot be used for post-op recovery |
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initial hospital care
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this is for the first hospital inpatient encounter by the admitting physician. If there are other initial inpatient encounters by physicians that are not the
admitting physician, look at the initial inpatient consultation codes or subsequent hospital care, as appropriate You can’t report two initial hospital care visits in the same day from the same episode. |
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To qualify as a consultation
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1. There must be a request by another physician
or other appropriate source asking a provider for their opinion 2. The consulting provider needs to render his/her opinion 3. The consulting provider needs to respond with a written report to the requesting provider |
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define a critical illness or injury
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one that acutely impairs one or more vital organ systems such that there is a high probability of
imminent or life threatening deterioration in the patient’s condition |
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Critical care
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billed in time increments. When calculating the time for critical care codes, include the total time spent by the physician on that date of service, even if it is not continuous.
If the total time of critical care is less than 30 minutes, bill the appropriate E/M code |
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Nursing Facility admission
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Services performed at other sites of services performed with the admission are considered
inclusive and are included in the Nursing Facility admission. Exceptions to this are hospital discharge and observation discharge services billed on the same date |
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ROS
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Constitutional- e.g. weight game
Eyes ENT Cardio Respir GI Genito/urinary Musculoskeletal Integumentary/ breasts Neuro Psychiatric Endocrine Hematological/lymphatic- edema, frequent Allergic/immunologic |
