Aapc: Chapter 19- Evaluation & Management

Front 1

auscultation

Back 1

listening to body organs

Front 2

chief complaint

Back 2

the reason the patient presents for an encounter

Front 3

counseling

Back 3

a discussion with a patient and/or family concerning diagnosis, prognosis, risk factors, etc.

Front 4

critical care

Back 4

provided for illness or injury which acutely impairs one or more vital organ systems, & is an imminent or life-threatening condition

Front 5

established patient

Back 5

a patient who has seen a provider of the exact same specialty & subspecialty in the same group within the past 3 years

Front 6

family history

Back 6

a review of the health status of immediate family, including cause & age of death

Front 7

history of present illness

Back 7

a chronological description of the onset & progression of the illness for which treatment is being sought

Front 8

new patient

Back 8

a patient who has not been seen by a provider of the exact same specialty & subspecialty in the same group for the past 3 years

Front 9

medical necessity

Back 9

reasonable & necessary services to effect cure or a change in the condition for which the patient is being seen

Front 10

observation status

Back 10

the patient’s condition requires monitoring but the decision to admit to inpatient status has not been made

Front 11

palpation

Back 11

touching the body during a physical examination in which an object is felt to determine size, shape, firmness, or location

Front 12

percussion

Back 12

creating sounds from the body by tapping

Front 13

review of systems

Back 13

a series of questions regarding signs & symptoms that are associated with the patient’s chief complaint

Front 14

domiciliary care

Back 14

care provided in a supervised home setting, including assisted living facilities

Front 15

preventative

Back 15

If there is not a chief complaint, the service is considered