E/M Fast Finder. CPT only 2012 American Medical Association. 1 All Rights Reserved.
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1 E/M Fast Finder The E/M Fast Finder is a carry-along reference to assist in assigning the Evaluation and Management (E/M) codes that are part of the series of Current Procedural Terminology (CPT ) codes. The convenient size and reference tables in the E/M Fast Finder make this an ideal coding tool whether the provider or coder is in the comfort of an office with coding resources at hand or is in a busy emergency department, ICU, or hospital unit far from a coding resource. The E/M Fast Finder can be invaluable in all of these situations. E/M codes have been part of CPT since 1992, the year the codes were introduced to clarify documentation of E/M services. CPT codes are under the auspices of the American Medical Association (AMA). The publication is updated annually to incorporate changes in medical technology and practice. For 2012, the AMA has refined the definition of new and established patient. Additional instruction was added to state that the provider must be of the exact same specialty and subspecialty. Although primary care and internal medicine are both considered to be primary care, they are not considered to be the exact same specialty. Questions may still remain regarding subspecialty. Medicare does not recognize many subspecialties and payers who use their designations may rely on the specialty designation only. Initial observation codes ( ) now include a time designation. The typical times associated are 30 minutes for 99218, 50 minutes for 99219, and 70 minutes for Descriptors of subsequent observation care codes already include time designations. Prolonged services guidelines were revised to indicate that the services are provided by a physician or other qualified health care professional. Note that the extension applies to recognized nonphysician providers such as a nurse practitioner, physician assistant, and certified nurse specialist; however, this revision does not extend to nursing or office staff. Further definition is given regarding prolonged services without direct patient contact. The guidelines now state that it CPT only 2012 American Medical Association. 1
2 Abbreviation Key Levels CC chief complaint Ex examination HPI history of present illness PHx past medical history FHx family history SHx social history PFSHx past medical, family and social history ROS review of systems Presenting Problem min. minimal sl/m self-limiting or minor ls low severity ms moderate severity hs high severity sri stable, recovering, improving rt mc responding to therapy or minor complication udsc np unstable, developing significant complications, or new problem Medical Decision Making Dx diagnoses Tx treatment 6 CPT only 2012 American Medical Association.
3 LEVEL Comprehensive Detailed Expanded Problem Focused Problem Focused HISTORY DEFINITION Chief complaint; extended Hx of present illness; complete system review; complete past, family and social history Chief complaint; ext. Hx of present illness and ext. systems review; pertinent past, family, and/or social history Chief complaint; brief Hx of present illness; problem pertinent system review Chief complaint; brief Hx of present illness or problem CPT only 2012 American Medical Association. 7
4 LEVEL Comprehensive Detailed EXAMINATION Expanded Problem Focused Problem Focused DEFINITION Complete single organ system specialty exam or general multi-system exam Extended exam of affected area(s) and other symptomatic or related organ system(s) Limited exam of affected body area/organ system and other symptomatic or related organ systems Exam limited to affected body area or organ system BODY AREAS Head, including the face Neck Chest, including breasts and axilla Abdomen Genitalia, groin, buttocks Back Each extremity ORGAN SYSTEMS Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lympathic/ Immunologic 8 CPT only 2012 American Medical Association.
5 Medical Decision Making Subcomponents Level (Two subcomponents must be met or exceeded) Complexity Number of Diagnoses or Management Options Amount and/or Complexity of Data Reviewed Risk of Complication Morbidityand/ or Mortality High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Limited Low Straight Forward Minimal Min/None Minimal CPT only 2012 American Medical Association. 9
6 Subsequent Observation Care 2 of 3 (Key) Level/Definition Comprehensive CC; extended HPI; complete ROS, complete PFSHx TIME EXAMINATION HISTORY MEDICAL DECISION MAKING (Two subcomponents must be met or exceeded) (MIN) Detailed CC; extended HPI; extended ROS pertinent PHx, FHx, and/or SHx Expanded Problem Focused CC; brief HPI; problem pertinent ROS Problem Focused CC; brief HPI Comprehensive Complete single system specialty Ex or complete multi-system Ex Detailed Extended Ex of affected area(s) and other symptomatic or related systems Expanded Problem Focused Limited Ex of affected area(s) and other symptomatic or related organ systems Problem Focused Ex limited to affected body area or organ system High Complexity Extensive Dx or Tx options; extensive amount/complx. of data high risk Mod. Complexity Multiple Dx or Tx options; moderate amount/complx. of data; moderate risk Low Complexity Limited Dx or Tx options; limited amount/complx. of data; low risk Straightforward Minimal Dx or Tx options; min or no amount/complx. of data; minimal risk Bedside/Floor/Unit Estimates only; use when counseling/coordination of care dominate 50% of encounter PRESENTING PROBLEM (See key on pg. 6) Severity or sri rtmc udsc np 20 CPT only 2012 American Medical Association.
7 Physician Standby Services Physican standby service requiring prolonged physician attendance Each 30 Min Case Management In Case Management services, a qualified health care professional directs and coordinates the care of a patient including initiating, supervising or managing access to health care services. Anticoagulant Management Initial 90 days of therapy Each subsequent 90 days Code requires a minimum of eight INR measurements. Code requires a minimum of three INR measurements. CPT only 2012 American Medical Association. 37
8 Medical Team Conferences Medical team conference, direct (face-to-face) contact with patient and/or family, includes face-to-face participation by a minimum of three qualified people from different specialties or disciplines who have provided face-to-face evaluations or direct treatment to the patient. These codes include documentation of participation, contribution, and recommendations of the conference; however, time spent record keeping or writing a report is not reported. Conferences of less than 30 minutes are not reportable. Only one team conference participant from the same specialty may report codes for the same encounter. Medical team conference, without direct (face-to-face) contact with patient and/or family, includes physician participation (code 93667) or nonphysician qualified health care professional (99368). Medical Team Conferences with Interdisciplinary Team of Health Care Professionals Direct (Face-to-Face) with patient and/or family Nonphysician Nonphysician Physician 30 minutes <30 minutes Not reportable Without Direct (Face-to-Face) Patient and/or Family Not Present 30 minutes <30 minutes Not reportable 30 minutes <30 minutes Not reportable 38 CPT only 2012 American Medical Association.
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