Medical Code 2 Flashcards
SOAP Notes translated to ICD
-S- what are the pts current complaints- what is the hx component, symptoms from the patient
-O- what are the relevant physical findings? Is there dx information?- what is the exam summary
-A- what is your assessment, differential dx, problem list? what are the **ICD codes*- diagnosis, indications, procedures
-P- further dx or therapeutic steps? what is the medical decision making- relate it back to assessment
3 components determine the cost of a typical pt visit/encounter
-History- CC, HPI, ROS , PFSH (past, family, social hx)
-physical exam- # of organ systems examined
-medical decision making: assessment and plan- # dx of management options, amount of data/complexity, risk level to pt
history component review
-component translated into level of complexity of hx:
-history of present illness- cannot be signed off by staff
-review of systems- can be documented by staff
-past, family and social history- PFSH
-these are classified into:
-problem focused
-expanded problem
-detailed comprehensive histories
examination summary
-4 types of physical examination
-Problem focused- 1-5 elements
-expanded problem- at least 6 elements
-detailed- 12 total in at least 2 systems
-comprehensive- at least 2 elements from at least 9 systems
problem focused
-objective component
-1-5 elements of one or more organ systems
-vital- Temp, BP, HR
-general appearance- NAD, conversant
-Lungs- CTA
-CV- RRR, no murmurs, rubs, or gallops
-1 bullet for 3 vital signs
-1 bullet for general appearance
-1 bullet for auscultation of lungs
-1 bullet for auscultation of the heart
expanded problem focused exam
-objective component
-6 elements from any organ system
-vitals- T, BP, HR
-general appearance- NAD, conversant
-lungs- clear to auscultation
-CV- RRR, no murmurs, rubs, or gallops
-abdomen- soft, nontender
-vascular- no peripheral edema
-1 bullet for three vital signs
-1 bullet for general appearance
-1 bullet for auscultation of lungs
-1 bullet for auscultation of the heart
-1 bullet for examination of the abdomen
-1 bullet for examination of extremities for edema
detailed exam
-at least 2 bullets from six organ systems or 12 bullets from 2 or more organ systems
-vitals- temp, bp, hr
-general appearance- NAD, conversant
-head- normocephalic, atraumatic
-neck- FROM, supple, trachea midline
-lungs- clear to auscultation
-CV- RRR, no MRGs, normal carotid upstroke and amplitude without bruits
-abdomen- soft, non-tender, no masses or HSM
-extremities- no peripheral edema or digital cyanosis
-skin- no rash, lesions, or ulcers
-neuro- alert and oriented to person, place and time
comprehensiv exam
-2 bullets from 9 organ systems
0Vitals: T:98.6, 120/80, 88
-General appearance: NAD, conversant
-eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA
-HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations
-normal hard and soft palate
-Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
-Lungs: CTA, with normal respiratory effort and no intercostal retractions
-CV: RRR, no MRGs
-Abdomen: Soft, non-tender; no masses or HSM
-Extremities: No peripheral edema or extremity lymphadenopathy
-Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules
-Neuro: Appropriate affect, alert and oriented to person, place and time
evaluation and management documentation guidlelines
-history- HPI, past, family, social, ROS
-physical exam
-medical decision making
medical decision making (MDM)
-4 levels of decision making
-based on # of diagnosis, complexity of data reviewed, and risk to patient:
-minimal- straight forward
-limited- low complexity
-multiple- moderate complexity
-extensive- high complexity
E/M services and documentation and medical decision making
-factors that determine the complexity of decision making:
-number of possible dx and/or number of management options
-amount and/or complexity of medical records, dx tests, and/or other information that must be obtained, reviewed, and analyzed
-risk of significant complications, morbidity, and/or mortality with the pts problems, the dx procedure, and/or the possible management options
-combination of these 3 elements determines the over al level of medical decision making
-more reimbursement for complicated cases bc icd codes and procedure codes and the time/expertise of the provider
documentation of exam
-extent of the exam performed “is dependent upon clinical judgement and the nature of the preventing problem”
-a notation of “abnormal” without elaboration is insufficient without explanation
-brief statement or notation of “Negative” or “normal” is sufficient to document normal findings related to unaffected areas or asymptomatic organ systems
-do not document excessive and unnecessary information soley to meet requirements of high level service when the nature of the visit dictates a lower level service to have been medically appropriate
Pt presents to office with lower back pain. You perform thorough history in 20 minutes. Your pt has unilateral loss of sharp touch in the right lower limb. there are paresthesias in the lateral foot
-Low back pain- R52.0
-disturbance of sensation- R20.0
-peripheral neuropathy lower extremity is G90.09
ICD
international classification of diseases
