2. Objectives: At the end of the session the students will be able to:
Perform diagnostic and procedural coding
Understand the three factors upon which evaluation and management
codes are based.
Discuss the four contributing factors
Review the three key components of patient services
Materials Required:
The Next Step textbook
CPT Code Book
3. The most often reported codes
in the CPT manual are those in
the Evaluation and
Management (E/M) section.
4. BASICS THREE FACTORS
The codes in the E/M section are
based on three factors:
1. Place of service
2. Type of service
3. Patient status
5. KEY COMPONENTS
The three key components are the history,
examination, and medical decision-
making complexity
6. Review of Systems (ROS).
The ROS is an inventory of the
body systems obtained through a
series of questions.
7. Past, Family, Social History.
The physician decides the extent of the PFSH
based on the needs of the patient.
8. History Levels
The level is based on the extent of the history.
1. Problem focused
2. Expanded problem focused
3. Detailed
4. Comprehensive
9. Examination
The history is the subjective information
The objective information is the findings of the
examination
10. S in regards to the SOAP
note is the subjective
information
O is the objective
information in the SOAP
note
11. The following are the four levels of examination
based on the extent of the examination:
1. Problem focused: Examination is limited
2. Expanded problem focused: A limited examination
of the affected BA or OS and other related BAs or OSs.
3. Detailed: An extended examination
4. Comprehensive: This is the most extensive examination
12. Medical Decision Making Complexity
The MDM is based on the complexity of
the decision the physician must make
13. History: There are three elements of the history
History of present illness, review of systems and personal family social history.
History of present illness-
Defined: The patient describes in his /her own words what happened to
them to bring them to see the doctor. For example when where and how
they got sick or injured. It is in the patient’s own words.
PHI key concepts: There are 8 key concepts to look for in the history of present
illness.
Location: where on the body is the problem
Quality: Adjectives describing the pain: sharp, stabbing, throbbing, dull
Severity: on a scale of 1-10, the worse I ever had
Duration: I have had this problem for 2 weeks, Last night I got a fever
Timing: When: In the morning I vomit, I fell in the afternoon
Context: Under what circumstances did it occur: E Code!!!
I fell, I was in a car accident, I was at work, I fell roller skating
Modifying factors: What made the situation better or worse?
I took a Tylenol for my headache, I wrapped my sprain ankle
Associated Signs and Symptoms: Fever with the cold, abrasions with the fracture
14. There are 4 types of history.
Problem focused
Expanded problem focused
Detailed
Comprehensive
1-3 elements is problem focused or expanded
problem focused
4 or more elements is detailed or comprehensive.
15.
16. Provider asks patient a series of questions (This is not a
physically exam).
1. Constitutional
2. Opthalmological (eyes)
3. Otorhinolarynological (ENMT)
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/ Immunologic
17. None is problem focused
1 is Expanded problem focused
2-9 is detailed
10 or more is comprehensive
18. Past, Family, Social History
This is obtained by asking the patient a series of questions.
Components: Are past illnesses. Operations, injuries,
treatments and current medications discussed?
Is the family history documented? We are looking for risk
factors.
If it says non- contributory, it is still documented.
Are social activities and employment documented?
Each component is worth one point.
19. Case 1-11 The history section only
History of Present Illness: She has been having problems with recurrent
peptic ulcer disease despite therapy with Zantac and Prilosec. She has
undergone recent endoscopies, which revealed a large ulcer that was
reported to be benign. The patient also noted to have a slightly elevated
CEA of 11. On June 30, the patient underwent laparoscopy which turned
out to be normal as well as benign. There were no signs of
lymphadenopathy.
Past Surgical history: Hysterectomy and Tubal ligation
The patient has never had a problem with anesthesia or surgery.
Social History: Positive for smoking. The patient denies alcohol abused
and smokes 1 pack per day.
Family History: Negative for colonic carcinoma, premature coronary artery
disease, but positive for severe peptic ulcer disease in her mother.
Allergies: none
Review of systems; melena, hematochezia and hematemesis
HPI – location peptic ulcer
Review of systems: Gastrointestinal -ulcer
PFSH – Personal – endoscopies, past surgical history
Social history – smoker
Family – mother positive for ulcer disease and negative for colon cancer
20. Scoring
HPI – detailed (1)
ROS – expanded problem focused (1)
PFSH – Comprehensive (3)
Level- expanded problem focused
21. Doctor physically examines the patient by touching the
patient.
Problem focused exam – looks only at the problem
Expanded problem focused – looks at 2-7 body systems.
It looks at the problem and few related organ systems
Detailed looks at 2-7 organ systems -It looks at the
problem and more organ systems
Comprehensive looks at 8 organ systems
22. Constitutional is worth one point regardless of the number of constitutional elements
examined.
Constitutional elements
Blood pressure pulse respiration temperature
Height weight general appearance
Body areas
Head neck chest – chest wall abdomen-exterior
Genitalia – groin back each extremity
Organ systems
1.Ophthalmologic – eyes, pupils examined – PERRlA
2. Otolaryngologic – ears nose mouth and throat.
3. Cardiovascular - heart, arteries and veins – heart sounds, regular rate and rhythm, pulses
present in extremities, edema
4. Respiratory – how the lungs and respiratory track work, no abnormal lung sounds no rales
and no crackles
5. Gastrointestinal – how the internal organs of the abdomen work – bowel sounds present,
bowel sounds absent.
6. Genitourinary – urination frequency or burning, discomfort during sex, erectile disfunction
7. Musculoskeletal – bones and muscles; reflexes present, bones intact
8. Integumentary – skin: rashes, abrasions, lacerations, lesions
9. Neurologic – nerves, cranial nerves intact, oriented times 3 = oriented to person place and
time.
10. Psychiatric – emotional stability –
11. Hematologic/Lymphatic/Immunologic – no lymphadenopathy
23. Read case 1-11 the physical exam section only.
When assessing the physical exam only read the physical exam section.
Exam: demonstrates a slender Hispanic female in no acute distress. She is
uncomfortable however, because of epigastric discomfort. Her neck is
supple. There is no thyromegaly or regional lymphadenopathy. No
subclavicular lymph nodes.
ENT: within normal limits.
EYE: Sclera anicteric. Conjunctive are pale.
Fundoscopic exam shows no AV nicking, hemorrhages exudates or
papilledema.
Chest is barrel shaped without dullness to percussion but with rhonchi
scattered throughout the lung fields. Prolonged expiratory phase was
noted.
Cardiac exam: Regular rhythm. Distant heart sounds; 1/6 systolic ejection
murmur at the base.
Abdomen is soft and tender to palpation; Epigastric area without rebound
tenderness or guarding. Liver span is 7 cm edge at right costal margin.
Aorta diameter is normal.
Extremities upper and lower leg show no edema and swelling.
Neurological exam is non-focal.
24. Exam – Constitutional – no acute distress (No points…no work involved)
Endocrine – no thyromegaly
Lymphatic – no lymphadenopathy
Ophthalmologic – eyes: conjunctive are pale
Chest: barrel shaped
Respiratory: rhonchi scattered in lung fields.
Cardiac: regular rhythm
Extremities – this exam is cardiovascular.
Neurological: non focal
Organ systems documented: 7
Body area documented: 1
Exam: Detailed
25. Medical Decision Making
There are 4 types of medical decision making.
Straight Forward
Low Complexity
Moderate Complexity
High Complexity
Items we look at 3 things for medical decision making.
Number of diagnosis or management options.
Amount and complexity of data to be reviewed
Risk of complication or death if not treated.
26. No of dx:
How many problems does the patient have?
How can we care for the patient.
Amount and complexity of data reviewed:
How many x-rays were reviewed?
Was blood work reviewed or ordered?
Was other information needed to make a decision
Risk of complication or death if the patient is not treated
Minimal – one minor self limited dx – insect bite
Low- one stable chronic illness
Acute uncomplicated illness
Moderate – one or more chronic illness
Two stable chronic illness
Undiagnosed new problem
Acute illness with systemic symptoms
Acute complicated illness
High - one or more chronic illnesses with sever manifestations
Acute or chronic illness that pose a threat to life
An abrupt change in neurological status. Such as stroke, cva,
27. The key component of
MDM represents the A
for assessment in the
SOAP note.
28. Case 1-11
Non healing peptic ulcer disease. Patient’s doctor increased her Prilosec
to 2 a day and continues Zantac at the present dose. In fact, one might
increase it to 300mg bid if necessary. There is certainly a need to rule out
Zollinger-Ellison and hyperparathyroidism as the source of the patient’s
non healing ulcer. C- Terminal PTH along with ionized calcium. One
might plan parahyperthyroidectomy simultaneous with gastrectomy if
the patient has high PTH, which I suspect is the case. Although in the
case of treatment with H2 blockers and Prilosec a gastrin level might be
elevated. Any how we will check it and make sure that it is not extreme.
If the gastrin level is high one might consider complete gastrectomy
rather than a partial one of the presumption of Z-E syndrome. The
patient will be evaluated after results of the tests are available and
scheduled for surgery. Elevated CEA is bothersome. She has not had
colonoscopy for some time and it should be evaluated again during the
same admission. The patient will be sent to Dr. Dawson. I am concerned
with her pulmonary status. She is advised to curtail her cigarette
consumption to as low as possible and switch to low tar nicotine
cigarettes in the interim. Once she is admitted, therapy with beta
agonists and Atrovent will be immediately initiated and the patient will
be started on incentive spirometry.
29. Number of dx
Peptic ulcer and tobacco abuse
Amount and complexity of data to review
Blood work
Risk to patient
Surgery required gastrectomy is needed.
Recheck blood work to see if a partial or total
Colonoscopy requested.
Evaluate thyroid.
Tobacco abuse affecting recovery
Medical decision making:
30. Putting it all together
Outpatient Consultation (POS, TOS, PT STAT)
Hx: Expanded Problem Focused
Exam: Detailed
Medical decision making: Low
31. POS TOS PATIENT STATUS
New Patient Established
HX EXAM MDM
Problem Problem Straight
Focused Focused Forward
Expand Prob. Expand Prob. Low
Focused Focused
Detailed Detailed Moderate
Comprehensive Comprehensive High
32. Lesson Tips
Practice exercise in the “The Next
Step” textbook and workbook for
Chapters 1
Use the Evolve website for coding
practice – https://evolve.elsevier.com
33. Summary
Today we learned the three factors upon which
evaluation and management codes are based
We discussed the four contributing factors
We learned the three key components of patient
services
We practiced some basic coding exercises from
the power point.
34. Next Steps:
We meet at the same time next week
Read Chapter 2 Medicine to prepare
for next week.
Work through as many of the
exercises as possible
Once you have identified the place of service, type of service, and patient status, you are ready to locate the information in the medical record that identifies the key components of the service.
The ROS may be asked by the physician, nurse, or by means of a questionnaire filled out by the patient or ancillary personnel. Regardless ofhow the information is obtained, before the information can qualify as an ROS, the physician must review the information and document the review in the medical record. The documentation includes both positive responses and pertinent negative responses related to the HPI.
The PFSH is a review of the past, family, and social history of the patient. Some encounters do not include any PFSH elements, whereasother encounters contain an extensive review of all elements.
The history is the subjective information the patient provides the physician, and the examination is the objective information the physician gathers. The examination is the findings that the physician observes during the encounter. The physician documents the examination in the medical record
1. Problem focused: Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA.2. Expanded problem focused: A limited examination of the affected BA or OS and other related BAs or OSs. It involves a limited examination of 2–7 BAs or OSs.3. Detailed: An extended examination of the affected BAs or related OSs. It involves an extended examination of 2–7 BAs or OSs.4. Comprehensive: This is the most extensive examination; it encompasses at least 8 OSs. For the purposes of this text, body areas will be counted for a comprehensive examination, although many coders only count organ systems
The key component of MDM is based on the complexity of the decision the physician must make regarding thepatient’s diagnosis and care.
None – Problem Focused None - Expanded problem focused 1 - Detailed 2-3 - Comprehensive
ScoringHPI – detailed (1)ROS – expanded problem focused (1)PFSH – Comprehensive (3)Level- expanded problem focused
Exam – Constitutional – no acute distressEndocrine – no thyromegalyLymphatic – no lymphadenopathyOphthalmologic – eyes: conjunctive are paleChest: barrel shapedRespiratory: rhonchi scattered in lung fields.Cardiac: regular rhythmExtremities – this exam is cardiovascular.Neurological: non focalOrgan systems documented: 7 Body area documented: 1Exam: Detailed
***When the Dr decides to treat the patient he discusses what he plans to do to the patient. He discusses how many illnesses the patient has. He also states what information he reviewed in order to make his decisions.
Number of dx: Peptic ulcer and tobacco abuseAmount and complexity of data to review: Blood workRisk to patient: Surgery required gastrectomy is needed. Recheck blood work to see if a partial or total Colonoscopy requested. Evaluate thyroid. Tobacco abuse affecting recoveryMedical decision making:
