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Medical Billing, Insurance, and Coding - Smith Fall 2020 > Chapter 11 > Flashcards

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Most frequently reported section in the CPT and is located first in the manual

E/M section


Types of services rendered

Office visits, hospital visits, and consultations


The assignment of codes from the E/M section is determined by three factors

1. place of service
2. type of service
3. patient status


Why are the place/type of service and patient status important in coding procedures and services in this section?

Place and type of service have an obvious impact on the complexity and cost of patient treatment


Place of service explains

the setting


Types of services include

consultations, admissions, office visits, prolonged services, etc.


define consultation

request to obtain an opinion or advice about a diagnosis or management option from another physician or other appropriate source


define admission

attention to an acute illness or injury that results in admission to a hospital


define office visit

face-to-face encounter physician and a patient that allows for primary management of the patient's health care status


Four patient status types consist of

new patient
established patient


Patient who has not received professional service in the past three years from the physician now providing services or from another physician with the exact same specialty and subspecialty who is in the same medical group as that physician

new patient


Why is the treatment of a new patient more labor intensive for physicians and staff than treatment of an established patient?

New patients require more extensive workups to determine their current medical status


Any patient not classified as as new

established patient


What differences would you expect in the way third-party payers process claims for new and established patients treated for the same condition during an office visit?

New patients require a higher level of service than do established patients, a higher level of reimbursement would be made for treatment of the new patient than for treatment of the established patient.


Patients that have not been formally admitted to a health care facility. Treated in a clinic, a same-day surgery center, or in a hospital under observation status



When are inpatient services coded?

Third-party carriers prohibit billing for both the original outpatient and subsequent inpatient services when delivered on the same day


Patients who have been formally admitted to a health care facility including a hospital or nursing facility



During inpatient visits, the physician may

admission orders, request consultations, order any services or procedures required to meet the patient's immediate needs following admission.


Must the admitting physician be present at the health care facility during the admission to bill for initial inpatient services required by the patient?

No. These services may be provided at another facility


Dictates admission orders, dictates history and physical examinations, requests consultations, and orders services and procedures

attending physician


Levels of E/M services are based on

documented evidence found in the patient's medical record of the nature of the presenting problem, and amounts of skill, effort required or assumed, time, responsibility, and medical knowledge used by the physician to provide service to the patient


foundation for the level of service

nature of the presenting problem


How would you expect the E/M level to change if a physician's assistant provided a service, rather than the physician?

A physician's assistant has less medical knowledge and less responsibility than the physician does. As a result, compensation may be less when services are performed by a PA


What is important when determining reimbursement for E/M services and procedures

level of service is the main consideration


The greater the level of each key component or contributory factor required to treat a patient, the ____ the level of service coded



Key components are

history, examination, and medical decision making


Contributory factors are

conditions that help the physician determine the extent of the history, examination, and decision making required to treat the patient


Four contributory factors used are

counseling, coordination of care, nature of the presenting complaint, and time


The nature of the presenting complaint will (2)

1. determine the need for counseling and coordination of care and whether time is a factor to be considered
2. influence the extent of history, examination, and decision making required


Four elements of a history

1. chief complaint
2. history of present illness
3. review of systems
4. past, family, and/or social history