Question

Fill in the job aid with information from the Coding from the Bottom Up article you have already read. Specifically, your job aid should include the following information:

1. Explain the history needed to assign each of the six E/M codes,
2. Explain the examination type needed to assign each of the six E/M codes, and
3. Explain the medical decision making needed to assign each of the six E/M codes.

Answer 1

1.E/M code. :- Evaluation and Management. Here patients physical care is degisnated. The history is 1. Complaint (chief). What really is for medicated?

2. Illness( present History.) What is the illness?

3. System ( review). Review the whole system process?

4.history of society,(social), family history, past of medicine ( medical). Some disease are genetic , so for their diagnosis , parents status , their past status related to health is done.

There are some level of history. 1. Comprehensive problem focused, 2. Problem focused, 3. Expanded problem focused. 4. Detailed problem.

Q.2. Examination type :- these are classified as

1. Physical :- now it is subdivided into :-

1.constitutional. general examination.

2.Eye :- here pupils and Iris are examined.

3. Ear ,nose , mouth, and throat :- external appearance of all these.

4. Cardiovascular, chest , gastrointestinal , lymphatic, skin , neurology.

Q. 3. Medical decisions making :- these are of some levels 1. Straight forward, 2. The complexity of decision must be moderate, 3. Complexity must be High, 4.Complexity is of Low. In these for new patient care is high. And level of service is also high.