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Abstracting the Level of Service with E/M Codes Read the mini medical record of each patient’s...

Abstracting the Level of Service with E/M Codes

Read the mini medical record of each patient’s encounter and answer the following questions.

  1. OFFICE                  Gender: F                            Age: 48

Status: Established

Chief Complaint: annual preventive care visit

History: pure hypercholesterolemia

Examination: comprehensive preventive care exam

Medical Decision Making: Cholesterol seems to be well controlled. No new problems.

  1. In what setting was the service provided?
  2. What type of service was provided?
  3. Is the patient new or established?
  4. What code range is applicable for this type of encounter?
  5. What is the title of the subcategory of the range of codes?
  6. What criteria are used to determine the level of service?
  7. What patient information meets these criteria?
  8. What CPT code(s) is/are assigned to this patient’s claim?
  1. INPATIENT HOSPITAL     Gender: M                          Age: 25

Chief complaint: patient admitted by me for hematuria.

History: Detailed. Extended HPI, extended ROS, pertinent PFSH

Examination: comprehensive GU exam

Medical Decision Making: moderate complexity

  1. In what setting was the service provided? 2.
  2. What type of service was provided?
  3. Is the encounter initial or subsequent?
  4. What code range is applicable for this type of encounter?
  5. What is the title of the subcategory of the range of codes?
  6. What criteria are used to determine the level of service?
  7. What level of examination was performed?
  8. What is the complexity of the medical decision making?
  9. How much time was spent in counseling and coordination of care?
  10. What CPT code(s) is/are assigned to this patient’s claim?
  1. NURSING FACILITY          Gender: F            Age: 87

Chief complaint: status post hip replacement

History: problem-focused history of patient whom I saw last week.

Examination: expanded problem-focused MS exam

Medical decision making: Straighforward. Patient is improving.

  1. In what setting was the service provided?
  2. What type of service was provided?
  3. Is the encounter initial or subsequent?
  4. What code range is applicable for this type of encounter?
  5. What is the title of the subcategory of the range of codes?
  6. What criteria are used to determine the level of service?
  7. What level of history was taken by the provider?
  8. What level of examination was performed?
  9. What was the complexity of medical decision making?
  10. What CPT code(s) is/are assigned to this patient’s claim?
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Answer #1

1.OFFICE                  Gender: F                            Age: 48

Status: Established

Chief Complaint: annual preventive care visit

History: pure hypercholesterolemia

Examination: comprehensive preventive care exam

Medical Decision Making: Cholesterol seems to be well controlled. No new problems.

a. In what setting was the service provided?

The service was provided at the office setting

b. What type of service was provided?

Preventive care and health checkups

c.Is the patient new or established?

Established patient

d.What code range is applicable for this type of encounter?

Established patient office or other outpatient visits — CPT codes 99211-99215.

e.What is the title of the subcategory of the range of codes?

Office or outpatient services

What criteria are used to determine the level of service?

Chief complaint

History of present illness

Review of system

Past, Family, and/or Social History (PFSH)

What patient information meets these criteria?

Chief complaint and past history

What CPT code(s) is/are assigned to this patient’s claim?

  • (85002–85999) hematology and coagulation

2. INPATIENT HOSPITAL     Gender: M                          Age: 25

Chief complaint: patient admitted by me for hematuria.

History: Detailed. Extended HPI, extended ROS, pertinent PFSH

Examination: comprehensive GU exam

Medical Decision Making: moderate complexity

a. In what setting was the service provided?

Hospital Inpatient

b. What type of service was provided?

Inpatient service for the management of hematuria

c. Is the encounter initial or subsequent?

Initial

d. What code range is applicable for this type of encounter?

Initial hospital care:99221–99223

e. What is the title of the subcategory of the range of codes?

Hospital Inpatient Services

f. What criteria are used to determine the level of service?

Detailed. Extended HPI, extended ROS, pertinent PFSH

g. What level of the examination was performed?

Comprehensive GU examination

h.What is the complexity of the medical decision making?

Moderate complexity

i. How much time was spent in counseling and coordination of care?

24-48 hours

j. What CPT code(s) is/are assigned to this patient’s claim?

  • (99221–99239) Hospital inpatient services

3. NURSING FACILITY          Gender: F            Age: 87

Chief complaint: status post hip replacement

History: a problem-focused history of patient whom I saw last week.

Examination: expanded problem-focused MS exam

Medical decision making: Straighforward. Patient is improving.

a. In what setting was the service provided?

Nursing facility

b. What type of service was provided?

A problem-focused examination to know the status of the hip replacement

c. Is the encounter initial or subsequent?

Initial

d. What code range is applicable for this type of encounter?

99304–99306

e. What is the title of the subcategory of the range of codes?

Nursing facility services

f. What criteria are used to determine the level of service?

Chief complaint and history

g. What level of history was taken by the provider?

a problem-focused history of patient .

h. What level of examination was performed?

expanded problem-focused MS exam

i. What was the complexity of medical decision making?

Straightforward.

j. What CPT code(s) is/are assigned to this patient’s claim?

  • (99304–99318) Nursing facility services
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