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CPT > E/M > Flashcards

E/M Flashcards

1
Q

Key Components

A
  1. History
  2. Exam
  3. MDM
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2
Q

Contributory Factors

A

1 counseling
2 coordination of care
3 nature of presenting problem
4 time

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3
Q

Elements of a History

A

1 chief complaint
2 HPI
3 ROS
4 PFSH

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4
Q

How many elements of HPI

A

8

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5
Q

Elements of HPI

A

1 location
2 severity
3 quality
4 duration
5 timing
6 context
7 modifying factors
8 associated signs and symptoms

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6
Q

How many elements of ROS

A

14

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7
Q

Elements of ROS

A

1 constitutional
2 eyes
3 ears, nose, mouth, throat
4 cardiovascular
5 respiratory
6 integumentary
7 musculoskeletal
8 neurology
9 psych
10 hemotalogic/lymphatic
11 allergic/immuno
12 endocrine
13 gastrointestinal
14 genitourinary

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8
Q

PFSH

A

Past Family and Social History

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9
Q

Nursing Services formerly known as

A

Skilled Nursing (SNF)
Intermediate Care (ICF)
Long-Term Care (LTCF)

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10
Q

Preventative care based on what

A

age

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11
Q

If significant problem encountered during preventative services add what

A

Modifier -25

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12
Q

Elements of MDM

A
  1. Number of diagnoses and manage management options
  2. Amount or complexity of date
  3. Risk of complications or death
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13
Q

Levels of preventative care based on

A

Age

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14
Q

Number of organ systems

A

12

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15
Q

12 Organ Systems

A

Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitounrinary
Musculoskeletal
Integamentary
Neuro
Psych
Hem/Lymph/Immuno

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16
Q

Number of Body Areas

A

10

17
Q

Body Areas

A

Head
Neck
Chest
Abdomen
Genetalia, groin, buttocks
Back
Each extremity (4)

18
Q

First consult is a consult code, second visit what kind of code

A

Subsequent hospital code

19
Q

3rd party payer requests consult add what

A

Modifier -32

20
Q

Exam levels

A

Problem Focused
Expanded Problem Focuses
Detailed
Comprehensive

21
Q

MDM Levels

A

Straighforward
Low
Moderate
High

22
Q

History Levels

A

Problem Focused
Expanded Problem Focused
Detailed
Comprehensive

23
Q

3 Factors of E/M Codes

A

Place of Service
Type of Service
Status of Patient

24
Q

Patient Status

A

Inpatient
Outpatient
New Patient
Established Patient

CPT (3 decks)

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