9/17/2018. Place of Service Type of Service Patient Status

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1 Place of Service Type of Service Patient Status 1

2 The first factor you must consider in code assingment is the place of service. Office Hospital Emergency Department Nursing Home Type of service is the reason the service us requested or performed. Consultation Admission Newborn Care Office Visit The four types of patient status are new patient, established patient, outpatient, and inpatient. 2

3 New has not received any face-to-face professional services from the physician/qualified health care professional, or a physician/qualified health care professional of the exact same specialty/subspecialty within the group practice, within the last three years. Established has received face-to-face services from the physician/qualified health care professional, or a physician/qualified health care professional of the exact same specialty/subspecialty within the group practice in the last three years. Outpatient is one who has not been formally admitted to a health care facility or a patient admitted for observation. Inpatient is one who has been formally admitted to a health care facility. 3 Key Components: History Examination Medical Decision Making Contributory Factors Counseling Coordination of Care Nature of presenting problem Time 3

4 Time can also be a stand alone factor when more than 50% of the time is spent counseling and/or coordination of care with the patient, and it is properly documented. You need to be able to identify the various elements and levels of a history by reading the notes entered into the medical record by the physician. Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH) The patient has presented the physician with the subjective information regarding the complaint or problem in the history portion of the encounter; now the physician will do an examination of the patient to provide objective information, hands-on about the complaint or problem. The physician then documents the objective findings in the patient record. 4

5 Based on the complexity of the decision the physician must make about the patient s diagnosis and care is based on three elements. Number of diagnoses or management options. The options can be minimal, limited, multiple, or extensive. Amount and/or complexity of the data review. The data can be minimal or none, limited, moderate, or extensive. Risk of complications or death if the condition goes untreated. Risk can be minimal, low, moderate, or high. Patient had to stay overnight in order to use these codes. Code it where it ended up when multiple related services provided on the same day Admitted and discharged on the same day Patient had to be there at least 8 hours Less than 8 hours code , as appropriate Used by the admitting provider (AI modifier used if Medicare) Used by consultants if Medicare 5

6 Three R s Request Render Respond 99285, Requires the three key components within the constraints. If provider is unable to obtain a history or complete an examination due to the patients urgent need, and the reason is clearly documented in the medical record, then the provider can still code Critical Care Services codes identify the services that are provided during medical emergencies to patients over 71 months of age who are either critically ill or injured. 6

7 There are service codes that are bundled into the Critical Care Services codes. These services are normally provided to stabilize the patient. Example: A physician starts ventilation management (94002) while providing critical care services to a patient in the intensive care unit of a hospital. The ventilator management is not reported separately but, instead, is considered to be bundled into the Critical Care Services code Outpatient Inpatient Non face to face 7

8 These codes are only for INPATIENT services provided to patients less than the age of 5 Make sure you have the right age category Initial vs. Subsequent, not based on time like codes A 50 year-old female was seen for the first time at Somewhere Facility Medical clinic by Dr. Alex. Her chief complaint was ear pain. She was diagnosed with acute otitis media in the right ear and treated with an antibiotic. A brief history of present illness and a problem pertinent system was reviewed. The examination was limited to the affected body area. Only one diagnosis, , was noted. No diagnostic test was ordered and medical record was completed noting no risk or morbidity or mortality. What evaluation and management code should be used to list services rendered? A 20-year-old male was dropped off in front of the hospital emergency department with a knife hilt sticking out of his mid-left anterior chest. The patient was not fully conscious. No one accompanied him. The patient was transported into the ED and the attending ED physician began the evaluation. Physical examination was less that comprehensive, but it was noted that whenever there was a peripheral pulse, the knife handle quivered. The attending ED physician initiated trauma team mobilization and ordered necessary diagnostics and fluid/blood replacement products. A partial history was obtained and documented by the attending ED physician s management. Twenty minutes after the patient was brought into the ED, the on-call trauma surgeon arrived in the ED, and the attending ED physician transferred care of the patient to the surgeon. The patients need for a high level E/M service and inability to provide a comprehensive history, as well as the unsuitability of an initial comprehensive examination, was evident in the medical record. How should the ED physician report services? 8

9 A 72 year-old female was seen in the emergency department of a city hospital within half an hour of a sudden onset of left hemiplegia and atrial fibrillation. The hospitals neurology acute stroke service was paged and the neurologists assumed responsibility for management of the patient. It was necessary for the neurologist to administer critical services. When the neurologists first evaluated the patient and performed the National Institutes of Health stroke scale in the emergency department, her blood pressure was 220/110 mm Hg. A computed tomography scan was performed and was normal in the judgment of the neurologist. The patient s blood pressure decreased to 180/110 mm Hg within one and one-half hours after the onset of her stroke. The neurologist reevaluated the patient and ordered administration of a thrombolytic agent in the emergency department, with an initial 10% bolus and the remainder administered during a one-hour period through an intravenous catheter infusion. The neurologist admitted the patient to ICU. When the infusion was complete and the neurologist had finished performing subsequent evaluations, the neurologist has spent approximately two and one-half hours managing and performing critical care services for the patient in the emergency department and the ICU. The ICU nursing staff continued to manage the patient s blood pressure and monitor her vital signs. What E/M services code(s) should the neurologist report? Define a new patient. At the initial office visit for a new patient, a 6 year-old boy with a 2 day history of lower abdominal pain with occasional vomiting, a detailed history is obtained including gastrointestinal system, fever, appetite, and characteristics of pain and bowel movements. A detailed examination is performed, including examination of the chest and abdomen and rectal examination. Medical decision making is of low complexity. Ordering of appropriate laboratory studies and initiation of plans for surgical consultation is also performed. What code(s) should be reported? 9

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