Question

Evaluation and Management Key Components Understanding the three key components that are used to properly identify the correct E/M level of service is essential for you to know as a medical coder. Reimbursement and compliance are closely tied to our accurate knowledge and expertise and these are the main elements of the job! For this discussion, consider your three key components: history, examination, medical decision making as you respond to each prompt. Apply your knowledge by including key component decision making for E/M services. Include the following aspects in the discussion: Select one key component to highlight in your own words Explain the importance of the elements that are included with this component Describe briefly the levels within the key component you selected Discuss the process you would use to determine the overall level of the key component selected.

Answer 1

There are 3 key components to Eevaluation and Management services. History, Exam and Medical decision making.

HISTORY

The reason for the patient encounter or Chief Complaint (CC)

The History of Present Illness (HPI)

Provides a review of systems based on the patient’s perspective

Past, Family and Social History (PFSH).

when documenting the history,then

• Clearly indicate the chief complaint.
• Describe the HPI in a way that the nature of the presenting problem is clear.
• Record positive and negatives.
• Use the term “non-contributory” for PFSH.
• Use “negative” for the system related to the presenting problem.

The Exam

The exam is an assessment of body areas or organ systems performed by the clinician,along with the medical history aids in determining the correct diagnosis and devising a treatment plan.

examples :-

• Cardiovascular .
• Ear, nose and throat .
• Eyes
• Genitourinary
• Hematologic/lymphatic/immunologic
• Musculoskeletal
• Psychiatric
• Respiratory
• Skin

when documenting the Exam ,

• A notation of “abnormal” of the symptomatic or affected area or organ systems without elaboration is not sufficient.
• Abnormal or unexpected findings of the examination of any asymptomatic body area or organ system should be described.
• A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected or asymptomatic areas or organ systems.

Medical Decision Making

4 types are there in E/M services.

•   Straigh tforward
• Low complexity
• Moderate complexity
• High Complexity

General Rules for documenting E/M services

• If it isn’t documented, it hasn’t been done.
• The medical record should be complete and legible.
• The documentation of each patient encounter should include:

- Reason for the encounter

- Assessment, clinical impression or diagnosis.

- Plan of care

- Legible identity of the observer along with the date of the signature

• Health risk factors should be identified
• The patient’s progress, response to and changes in treatment and revision of diagnosis should be documented
• The information in the medical documentation should support the diagnosis codes billed.ie;select the appropriate level of E/M service.