Podcast
Questions and Answers
What are the three key factors to consider when selecting an E/M code?
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?
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?
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?
What is the highest complexity level of medical decision-making?
Which of the following is NOT one of the levels of Examination?
Which of the following is NOT one of the levels of Examination?
Which level of history involves a thorough exploration of a patient’s medical experiences?
Which level of history involves a thorough exploration of a patient’s medical experiences?
How many elements are involved in taking a history?
How many elements are involved in taking a history?
Which level of medical decision making involves minimal risk and complexity?
Which level of medical decision making involves minimal risk and complexity?
During the history-taking process, which component includes the patient’s current medications and allergies?
During the history-taking process, which component includes the patient’s current medications and allergies?
What is NOT a type of history that might be taken during a patient examination?
What is NOT a type of history that might be taken during a patient examination?
Which type of examination level provides the least detail?
Which type of examination level provides the least detail?
What does the Straightforward level of medical decision-making indicate?
What does the Straightforward level of medical decision-making indicate?
Which factor is NOT part of the four elements of a history?
Which factor is NOT part of the four elements of a history?
Which history type specifically documents the patient's current status and background information?
Which history type specifically documents the patient's current status and background information?
Which level of History is considered the most thorough?
Which level of History is considered the most thorough?
Which of the following accurately describes the Expanded problem focused examination level?
Which of the following accurately describes the Expanded problem focused examination level?
In which medical decision-making complexity level would you classify multiple diagnoses and extensive data?
In which medical decision-making complexity level would you classify multiple diagnoses and extensive data?
What is typically documented during a History of Present Illness?
What is typically documented during a History of Present Illness?
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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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