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63 Cards in this Set
- Front
- Back
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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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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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HPI - How intense or on a scale of 1/10? ex. states pain is a 5 of a scale of 1/10
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Severity
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HPI - How long for this problem or episode? ex. pain began last Monday
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Duration
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HPI - When does it occur? ex. several times throughout the week.
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Timing
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HPI - Under what circumstances does it occur? ex. when he was bending over.
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Context
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HPI - What makes it better or worse? ex. icing the area provided some relief
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Modifying Factors
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HPI - What else is happening when it occurs? ex. some dizziness during these episodes
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Associated Signs and Symptoms
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1 of 2/4 Levels of HPI - How many elements are required for - Problem focused and Expanded problem focused?
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Problem Focused & Expanded P. F. (Brief 1-3 elements) review of the problems of why the pt. is being seen that day.
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2 of 2/4 Levels of HPI - How many elements are required for Detailed and Comprehensive?
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Detailed and Comprenshive levels of hx contain (4 or more) review of the HPI elements.
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3 of 4 of the Key components 1. ROS-review of systems - requires what? 2. By whom? 3. To qualify requires what?
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1. Inventory of body systems to identify signs and sx's. 2. Dr, Nurse, Questionaire 3. Dr. document pertinent + or - responses to quality
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ROS - Review of Systems contain how many and what are they?
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14 - Constituitional, Ophthalomologic, Otolaryngologic, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal
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Part 2 of ROS list
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Integumentary, Neurologic, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic
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Constituitional symptoms
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Usual weight, recent weight changes, fever, weakness, fatigue
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ROS List-
Eyes - Ophthalmologic |
Glasses or contact lenses, last eye exam, visual glaucomea, cataracts, eyestrain, pain, diplopia, redness, lacrimation, inflammation, blurring
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ROS List-
Ears, Nose Mouth,Throat - Otolaryngologic |
EARS - hearing, discharge, tinnitus, dizziness, pain, NOSE - head colds, epistaisis, discharges, obstruction, postnasal drip, sinus pain
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ROS List-
Ears, Nose Mouth,Throat - Otolaryngologic |
MOUTH and THROAT - condition of teeth and gums, last dental exam, soreness, redness, hoarness, difficulty in swallowing
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ROS List-
Cardiovascular |
chest pain, rhematic fever, tachycardia, palpitation, high BP, edema, vertigo, faintness, varicose veins, thrombophlebitis
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ROS List-
Respiratory |
Chest pain, wheezing, cough, dyspnea, sputum (color and qty), hemptysis, astma, bronchitis, emphysema, pneumonia, TB, pleurisy, last chest radiograph
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ROS List-
Gastrointestinal - , |
Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowel habits, diarrhea, constipation,
indigestion, food intolerance, flatus,hemorrhoids, jaundice |
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ROS List-
Genitourinary Urinary |
frequent or painful urination, nocturia, pyruia, hematuria, incontinence, urinary infection
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ROS List-
Genitoreproductive - Male |
Venereal dz, sores, discharge form penis, hernias, testicular pain or masses
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ROS List-
Genitoreproductive - Female |
age at menstrual,(frequency/type/duration/dysmenorrhea/menorrhagia, sx's of menopause) contraception, pregnacies , deliveries, abortions, last pap
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ROS List-
Musculoskeletal |
Joint pain or stiffness, arthritis, gout, backache, ms pain, cramps, swelling, redness, limitation in motor activity
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ROS List-
Integumentary (skin or breast) |
rashes, eruptions, dryness, cyanosis, jaundice, changes in skin, hari, or nails
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ROS List-
Neurologic |
Faintness, blackoutsk, seizures, paralysis, tingling, tremors, memory loss
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ROS List-
Psychiatric |
Personality type, nervousness, mood, insomnia, headache, nightmares, depression
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ROS List-
Endocrine |
Thyroid trouble, heat or cold intolerance, excessive sweating, thrist, hunger, or urination
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ROS List-
Hematologic/Lymphatic |
Anema, easy bruising or bleeding, past transfusions
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ROS List-
Allergic/Immunologic |
Sneezing, itching eyses, rhinorrhea, nasal obstruction, or recurrent infections Environment allergies, such as dust, mold or latex
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Past history - review of the pt's experience w/ illnesses, injuries, tx's includes what?
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Prior major illnesses, injuries, operations, hospitalizations, current meds, allergies, age-appropriate immunizations, feeding/dietary status
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Family history - review of medical events in the pt's family that include what?
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Health status or cause of death of parents, siblings, children/Dz's related to CC, HPI, or ROS, hereditary dz's place pt. at risk
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Social history - age appropriated review of past and current activities that include what?
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Marital status/living arrangements, current job, job hx, use of drugs, alcohol, tobacco, level of Education, Sexual history, etc
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Only 2 levels for PFSH
1 Pertinent and 2-3 Complete |
Level 1-Problem focused and Level 2-Expanded problem focused Do not require any PFSH elements
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Level 3-Detailed requires how many elements of PFSH?
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Only 1 pertinent element.
Ex. CC allergic rash. Dr. would inquire about pt's past hx of allergies - drugs, food, etc. |
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Level 4-Comprehensive requires how many elements of PFSH?
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At least 2 of 3 Complete elements. Ex. intermittent chest pains - Family.hx of heart dz, & Social.hx use of tobacco and diet
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4 Levels of histories - based on the extent of tx during the Dr/pt. encounter
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1. Problem focused 2. Expanded problem focused 3. Detailed 4. Comprehensive
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Level 1-Problem Focused
Dr. focuses on the CC and a brief hx of the present problem of the pt. requires what? |
Review of the hx re: pertinent info about the CC. Brief hx about the severity, duration, and sx's. Does not need the PFSH or ROS.
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Level 2-Expanded problem focused - Dr. focuses on CC, brief hx & a problem pertinent ROS. Does not need a PFSH.
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Hx is on specific Q's re: the OS closely related to the CC. Requires 1-3 HPI, 1 OS, & no PSFH elements. ex.swollen knee - Musculoskeletal system
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Level 3-Detailed- Dr. focuses on CC & obtains an extended hx of the present problem, ROS, and pertinent PFSH
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Extended=includes ROS related to the CC + addt'l related systems. Min. 4 HPI, 2-9 ROS, at least 1 PFSH element.
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Think about it!!!!! HPI-L. knee hurts, when I walk up the stairs PFSH-smoker, fast food eater ROS-blurred double vision, hearing ok, no dyspnea
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HPI-location, context PFSH-Social ROS-Ophth, Ears, Respiratory
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Level 4-Comprehensive-Dr documents th CC, obtains extended hx of present problem, a complete ROS & complete PFSH
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Requires an extended. HPI - 4 of the 8 elements, complete ROS min. 10 of 14 OS's, Complete review of all 3 PFSH
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The basis of the hx portion of the E/M services requires what 4 elements?
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1. CC 2. HPI 3. ROS 4. PFSH
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In Exam-
Body Areas consist of? |
7 areas-Head(incl.head), Neck, Chest(incl. breasts & axillae), Abdomen, Genitalia(groin, buttocks), Back, Each extremity
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In Exam-
Organ Systems consist of? |
Ophthalm., Otolaryn., Cardiovascular, Resp., Gastro., Genito, Musculo., Integumentary, Neurologic, Psychiatric, Hematologic/Lymphatic/
Immunologic |
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4 Levels of histories - based on the extent of tx during the Dr/pt. encounter
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1. Problem focused 2. Expanded problem focused 3. Detailed 4. Comprehensive
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Level 1-Problem Focused
Dr. focuses on the CC and a brief hx of the present problem of the pt. requires what? |
Review of the hx re: pertinent info about the CC. Brief hx about the severity, duration, and sx's. Does not need the PFSH or ROS.
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Level 2-Expanded problem focused - Dr. focuses on CC, brief hx & a problem pertinent ROS. Does not need a PFSH.
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Hx is on specific Q's re: the OS closely related to the CC. Requires 1-3 HPI, 1 OS, & no PSFH elements. ex.swollen knee - Musculoskeletal system
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Level 3-Detailed- Dr. focuses on CC & obtains an extended hx of the present problem, ROS, and pertinent PFSH
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Extended=includes ROS related to the CC + addt'l related systems. Min. 4 HPI, 2-9 ROS, at least 1 PFSH element.
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Think about it!!!!! HPI-L. knee hurts, when I walk up the stairs PFSH-smoker, fast food eater ROS-blurred double vision, hearing ok, no dyspnea
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HPI-location, context PFSH-Social ROS-Ophth, Ears, Respiratory
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Level 4-Comprehensive-Dr documents th CC, obtains extended hx of present problem, a complete ROS & complete PFSH
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Requires an extended. HPI - 4 of the 8 elements, complete ROS min. 10 of 14 OS's, Complete review of all 3 PFSH
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The basis of the hx portion of the E/M services requires what 4 elements?
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1. CC 2. HPI 3. ROS 4. PFSH
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In Exam-
Body Areas consist of? |
7 areas-Head(incl.head), Neck, Chest(incl. breasts & axillae), Abdomen, Genitalia(groin, buttocks), Back, Each extremity
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In Exam-
Organ Systems consist of? |
Ophthalm., Otolaryn., Cardiovascular, Resp., Gastro., Genito, Musculo., Integumentary, Neurologic, Psychiatric, Hematologic/Lymphatic/
Immunologic |
