CPT and E/M Codes Overview (Pg.33-34)

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Questions and Answers

What are the three key factors to consider when selecting an E/M code?

  • Patient demographics, examination details, previous visits
  • History, examination, medical decision making (correct)
  • Diagnosis, treatment, patient follow-up
  • Medical history, physical exam, treatment plan

Which type of history reviews the medical history of the patient’s family?

  • Past Medical History
  • History of Present Illness
  • Social History
  • Family History (correct)

In CPT coding, what does the abbreviation PFSH stand for?

  • Past, Family and Social History (correct)
  • Personal Focused Social History
  • Patient Functionality and Social Habits
  • Present Family and Social Hospitalization

What is the highest complexity level of medical decision-making?

<p>High (A)</p> Signup and view all the answers

Which of the following is NOT one of the levels of Examination?

<p>Minimal (A)</p> Signup and view all the answers

Which level of history involves a thorough exploration of a patient’s medical experiences?

<p>Comprehensive (D)</p> Signup and view all the answers

How many elements are involved in taking a history?

<p>Four (D)</p> Signup and view all the answers

Which level of medical decision making involves minimal risk and complexity?

<p>Straightforward (B)</p> Signup and view all the answers

During the history-taking process, which component includes the patient’s current medications and allergies?

<p>Past Medical History (C)</p> Signup and view all the answers

What is NOT a type of history that might be taken during a patient examination?

<p>Psychological History (B)</p> Signup and view all the answers

Which type of examination level provides the least detail?

<p>Problem focused (C)</p> Signup and view all the answers

What does the Straightforward level of medical decision-making indicate?

<p>Minimal complexity of data (D)</p> Signup and view all the answers

Which factor is NOT part of the four elements of a history?

<p>Medical history evaluation (B)</p> Signup and view all the answers

Which history type specifically documents the patient's current status and background information?

<p>Social History (C)</p> Signup and view all the answers

Which level of History is considered the most thorough?

<p>Comprehensive (A)</p> Signup and view all the answers

Which of the following accurately describes the Expanded problem focused examination level?

<p>A moderate level of detail focusing on existing problems (A)</p> Signup and view all the answers

In which medical decision-making complexity level would you classify multiple diagnoses and extensive data?

<p>High (D)</p> Signup and view all the answers

What is typically documented during a History of Present Illness?

<p>Development of current symptoms (C)</p> Signup and view all the answers

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Study Notes

Current Procedural Terminology (CPT)

  • CPT serves as Level I of the Health Care Common Procedural Coding System (HCPCS), essential for healthcare provider coding.
  • The structure includes a main text consisting of code sections, supplemented by appendixes and an index for easy navigation.

Evaluation and Management (E/M) Codes

  • Three key factors influence the selection of an E/M code: history, examination, and medical decision making.

Patient Examination and Documentation

  • History is a critical component, documented in the patient's medical file, often taken by healthcare assistants or physicians, serving as a reference for diseases or symptoms.

Types of Histories

  • History of Present Illness (HPI): Chronological description from the first symptom to present.
  • Past Medical History (PMH): Includes past illnesses, injuries, treatments, surgeries, current medications, allergies, and immunizations.
  • Family History (FH): Reviews health issues in the patient’s family to identify hereditary conditions.
  • Social History (SH): Encompasses the patient's demographic details such as age, marital status, and employment information.

Elements of History

  • Comprises Chief Complaint, Present Illness, Symptoms Review, and PFSH (Past, Family, Social History).

History Levels

  • Problem Focused: Brief history limited to the chief complaint.
  • Expanded Problem Focused: Includes additional history pertinent to the problem.
  • Detailed: Comprehensive history covering multiple areas.
  • Comprehensive: Extensive history, often includes complete PFSH.

Examination Levels

  • Mirrors history levels, ranging from Problem Focused to Comprehensive, evaluating the depth and detail of the patient assessment.

Medical Decision-Making Complexity Levels

  • Ranges from Straightforward to High complexity, based on diagnoses, risks, and data complexity:
    • Straightforward: Minimal diagnoses and risks; minimal data complexity.
    • Low: Limited diagnoses and risks; limited data.
    • Moderate: Multiple diagnoses; moderate risk; moderate data complexity.
    • High: Extensive diagnoses; high risk; extensive data complexity.

Current Procedural Terminology (CPT)

  • CPT serves as Level I of the Health Care Common Procedural Coding System (HCPCS), essential for healthcare provider coding.
  • The structure includes a main text consisting of code sections, supplemented by appendixes and an index for easy navigation.

Evaluation and Management (E/M) Codes

  • Three key factors influence the selection of an E/M code: history, examination, and medical decision making.

Patient Examination and Documentation

  • History is a critical component, documented in the patient's medical file, often taken by healthcare assistants or physicians, serving as a reference for diseases or symptoms.

Types of Histories

  • History of Present Illness (HPI): Chronological description from the first symptom to present.
  • Past Medical History (PMH): Includes past illnesses, injuries, treatments, surgeries, current medications, allergies, and immunizations.
  • Family History (FH): Reviews health issues in the patient’s family to identify hereditary conditions.
  • Social History (SH): Encompasses the patient's demographic details such as age, marital status, and employment information.

Elements of History

  • Comprises Chief Complaint, Present Illness, Symptoms Review, and PFSH (Past, Family, Social History).

History Levels

  • Problem Focused: Brief history limited to the chief complaint.
  • Expanded Problem Focused: Includes additional history pertinent to the problem.
  • Detailed: Comprehensive history covering multiple areas.
  • Comprehensive: Extensive history, often includes complete PFSH.

Examination Levels

  • Mirrors history levels, ranging from Problem Focused to Comprehensive, evaluating the depth and detail of the patient assessment.

Medical Decision-Making Complexity Levels

  • Ranges from Straightforward to High complexity, based on diagnoses, risks, and data complexity:
    • Straightforward: Minimal diagnoses and risks; minimal data complexity.
    • Low: Limited diagnoses and risks; limited data.
    • Moderate: Multiple diagnoses; moderate risk; moderate data complexity.
    • High: Extensive diagnoses; high risk; extensive data complexity.

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