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Upcoding
The deliberate increase in a CPT-4 code to receive higher reimbursement
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E/M codes were added to CPT in ...
1992
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Who always bills for E/M services?
Specialty physicians
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E/M codes represent what percent of Medicare Part B payments to doctors?
65%
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What services are included in the E/M section?
- *well and sick visits
- *case mgmt services
- *preventative and prolonged services
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3 components of E/M codes
history, examination, medical decision making
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What is a Chief Complaint (CC)?
A concise statement describing the symptoms, problem, condition, Dx that describes the reason for the visit, usually stated in the pt's own words
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Define concurrent care.
The provision of similar services (Example: hospital visits to the same pt by more than one doctor on the same day)
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History of Present Illness:
chronological description of the development of the patient's present illness from the first symptom to the present
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System Review:
Inventory of body systems obtained through a series of questions seeking to identify signs and symptoms that the patient may be experiencing
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New patient:
completely new patient OR a patient who hasn't been seen for 3+ years
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Established patient:
Patient who has received care within the last 3 years
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Is there is distinction made between new or established patients for an emergency department visit?
no
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Categories of E/M (there are 7 listed)
- *office/outpatient
- *hospital observation services
- *hospital inpatient
- *consultations
- *emergency department services
- *nursing facility services
- *home service
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Define morbidity.
state of being diseased
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Define comorbidity.
a disease coexisting with the primary disease
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example of comorbidity
primary Dx: cancer & the comorbidity is emphysema
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E/M services include:
Exams, evaluations, treatments, conferences with or concerning patient, preventative pediatric and adult health supervision
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Name the 6 components that are used in defining the levels of E/M services.
history, exam, medical decision making, counseling, coordination of care, nature of presenting problem, time... the first three are KEY COMPONENTS when selecting the code
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Which 2 components of the 7 (that are used to define the levels of E/M services are considered contributory factors in the majority of visits?
counseling, coordination of care, nature of presenting problem
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DEFINITION OF E/M COMPONENTS:
History
Pt history is needed (all four types-- problem focused, expanded problem focused, detailed history, comprehensive history)
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What is the difference between detailed history and comprehensive history?
- -Detailed includes CC, extended history of patient illness, extended system review, PERTINENT past, family and/or social history
- -comprehensive includes all of these but includes COMPLETE past family and social history
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Presenting problem definition: minimal
problem may not require the presence of the doctor but service is provided under the doctor's supervision
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Presenting problem definitions: self-limited or minor
Problem that runs a definite prescribed course
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Presenting problem definitions: low severity
Problem where risk of morbidity without treatment is low
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Presenting problem definitions: moderate severity
problem where risk of morbidity without treatment is moderate
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Presenting problem definitions: high severity
Problem where risk of morbidity without treatment is high to extreme
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Do you use a dash or just a space when adding a modifier?
just a space
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