Flashcards in Chapter 11 Deck (142)
Most frequently reported section in the CPT and is located first in the manual
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
Types of services include
consultations, admissions, office visits, prolonged services, etc.
request to obtain an opinion or advice about a diagnosis or management option from another physician or other appropriate source
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
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
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
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
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