The levels of Evaluation and Management (E/M) services are based on four types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. Each type of history includes some or all of the following elements: Show
Key Components
Contributory Factors
Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors. The extent of history of present illness, review of systems, and past, family and/or social history The chart below shows the progression of the elements required for each type of history. To
Chief Complaint (CC): A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record. History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the following elements:
IntroductionThe Current Procedural Terminology (CPT) manual, published annually by the American Medical Association (AMA) has definitive documentation guidelines that are required for each level of service code within the various E&M categories. The E&M categories for office/outpatient; office and in-patient consultations; and emergency room services each have five levels of coding. The E&M categories of initial and subsequent hospital visits each have three levels of coding. The seven components to the code selection are:
The charts that follow address the three KEY components to consider when selecting the level of code:
New patients and consultations require that the three key components be met or exceeded. Established patients and subsequent visits require that two of the three key components be met or exceeded. Code SelectionThe information provided at the top of the chart for each category will inform you if three or two key components must be met or exceeded to select the code.
Determine the Level of HISTORY
CC=chief complaint; HPI=hx of present illness; ROS=review of systems; PFSH=past family social hx Determine the Level of EXAMINATION
Determine the COMPLEXITY of MEDICAL DECISION MAKING
Decision Making (2 of 3 required)
1. Dx and Management Options TOTAL = _______ 2. Amount and /or Complexity of Data TOTAL = ________ Documentation Guidelines for CPT Evaluation and Management ServicesDetermine the Level of EXAMINATION
Determine the COMPLEXITY of MEDICAL DECISION MAKING
Decision Making (2 of 3 required)
1. Dx and Management Options TOTAL = _______ 2. Amount and /or Complexity of Data TOTAL = ________ Decision Making (2 of 3 required)
1. Dx and Management Options TOTAL = _______ 2. Amount and /or Complexity of Data TOTAL = ________ Table of RiskTotal is equal to the highest level of risk in any one category. This table is to be used as a guideline for risk. It is not considered to be comprehensive. TOTAL = _________ (Total = highest risk in any one category)
Outpatient/Office Coding
Inpatient Coding
What are the four elements of history in CPT coding?Otolaryngology Coding Alert
Answer: For a comprehensive history, you need to meet or exceed the following four elements: a chief complaint, an extended HPI, a complete ROS, and a complete PFSH.
What are the 3 key components a coder must consider when selecting an E&M code?The chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family and/or social history (PFSH) are the four components of patient history as required by the E/M documentation guidelines.
When selecting a type of history what four main types of information should the coder review?To determine the type of history for an E/M code, you must be aware of these four elements:. Chief complaint.. History of present illness.. System review (also called review of systems). Past, family, and/or social history.. What are the 3 elements that need to be documented by the provider to support their current procedural terminology CPT code?The charts that follow address the three KEY components to consider when selecting the level of code: History. Exam. Medical Decision Making.
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