Chapter 8 Short Notes Flashcards Preview

Medical Billing, Insurance, and Coding - Smith Fall 2020 > Chapter 8 Short Notes > Flashcards

Flashcards in Chapter 8 Short Notes Deck (29)
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1

Assignment codes from the E/M section is determined by three factors

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

2

assignment code that explains the setting

place of service

3

Office visits may include...

routine physical examinations or problem-focused examinations of limited scope

4

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

consultation

5

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

admission

6

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

office visit

7

patient who has not received professional health service in the past three years

new patient

8

any patient not classified as new

established patient

9

patients that have not been formally admitted to a health care facility

outpatient

10

patients who have been formally admitted to a healthcare facility including a hospital or nursing facility

inpaitent

11

foundation for the level of service

nature of the presenting problem

12

main consideration when determining reimbursement for E/M services and procedures

level of service

13

key components in E/M levels are...

history, examination, and medical decision making

14

contributory factors in E/M levels are...

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

15

the nature of the presenting complaint will...

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

16

four elements of a history are...

CC, HPI, ROS, and PFSH

17

chronological description of how the patient's present illness developed from the first sign and/or symptom or from the previous encounter to the present

HPI

18

Level of History: brief

1 to 3 elements are in the notes

19

Level of History: extended

4 or more elements are in the notes

20

thorough inventory of anatomical body systems obtained through a series of questions designed to identify signs and symptoms the patient may be experiencing

ROS

21

Problem-pertinent ROS includes

the patient's responses for the symptoms related only to the problem

22

Expanded ROS includes

the patient's responses for 2 to 9 of the systems

23

Complete ROS includes

the system(s) noted in the HPI and all additional body systems; at least 10 of the 14 systems must be reviewed

24

patients illnesses, operations, hospitalizations, injuries, allergies, current medications, immunizations, and dietary status

past history

25

set of questions relating to past and current activities common for the patient's age

social history

26

includes the medical events in the patient's family including diseases that may be hereditary, could put the patient at risk, or are relevant to the patient's chief complaint

family history

27

new patients office visits include

all 3 areas of PFSH

28

established office visits include

2 of the 3 areas of PFSH

29

initial visits require

1 of the 3 areas of PFSH