Professional Documents
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© Copyright 2006 American Health Information Management Association. All rights reserved.
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Step 1: Listen to the seminar, via Webcast link, audio CD, or MP3.
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of their completed quiz.
After listening to the seminar, please let us know what you think, by completing our online
evaluation survey at http://campus.ahima.org/audio/fastfactsresources.htm
i
Faculty
Susan M. Hull, MPH, RHIA, CCS, CCS-P
Susan M. Hull, MPH, RHIA, CCS, CCS-P is a professional practice resources manager
for the American Health Information Management Association (AHIMA). In her role as
manager, Susan provides professional expertise to AHIMA members, the media, and
outside organizations on coding practice issues, and develops written products aimed
at furthering the art and science of coding.
Susan has over 20 years experience in the HIM field. Before joining AHIMA in 2002,
she served as Senior Executive Director for HMI Corporation where she oversaw
coding reviews; chargemaster maintenance and development; and presented seminars
in outpatient, inpatient, and physician documentation and coding. Prior to this, she
worked in numerous HIM roles, including consultant, HIM department director, and
HIM software developer and manager.
Susan received a bachelor of arts degree and a master of public health in Health
Services and Hospital Administration from the University of California, Los Angeles.
ii
Table of Contents
Disclaimer ..................................................................................................................... i
How to earn one (1) CEU for participation ......................................................................... i
Faculty .........................................................................................................................ii
Basis for E&M level coding .............................................................................................. 1
New vs. established patients ........................................................................................... 1
History ........................................................................................................................ 2
Review of systems.............................................................................................. 2
PFSH ................................................................................................................. 3
Time as a determining factor........................................................................................ 4-5
Who may document ....................................................................................................... 5
Physical examination ................................................................................................... 6-7
Physical examination (1995 guidelines) ............................................................................ 7
Physical examination (1997 guidelines) ............................................................................ 8
Medical decision making ................................................................................................. 8
Categories of problems ....................................................................................... 9
Categories of data reviewed ................................................................................ 9
Management options .........................................................................................10
Summary......................................................................................................................11
1
Assigning E&M Code Levels Notes/Comments
History
• Constitutional • Musculoskeletal
• Eyes • Integumentary
• ENT • Neurological
• Cardiovascular • Psychiatric
• Respiratory • Endocrine
• Gastrointestinal • Hematologic/lymphatic
• Genitourinary • Allergic/immunologic
2
Assigning E&M Code Levels Notes/Comments
History — PFSH
• Past history
• Prior major illnesses, injuries,
hospitalizations and operations
• Current medications
• Allergies
• Immunization status (age appropriate)
• Feeding/dietary status (age appropriate)
Continued…
5
• Family history
• Significant inherited conditions
• Anything that might place the patient at risk
• Social history
• Marital status/living arrangements
• Occupational history
• Use of drugs, alcohol, tobacco
• Educational history
• Sexual history
3
Assigning E&M Code Levels Notes/Comments
Continued…
8
4
Assigning E&M Code Levels Notes/Comments
10
5
Assigning E&M Code Levels Notes/Comments
Physical examination
11
12
6
Assigning E&M Code Levels Notes/Comments
• 1995 guidelines
– based on either body areas or organ systems
• For purposes of examination, the following body
areas are recognized:
• Head, including the face
• Neck
• Chest, including breasts and axillae
• Abdomen
• Genitalia, groin, buttocks
• Back, including spine
• Each extremity
13
14
7
Assigning E&M Code Levels Notes/Comments
• 1997 guidelines
• General multisystem examination
• Single system (specialty) examination
• Cardiovascular
• Ears, Nose, Mouth and Throat
• Eyes
• Genitourinary (Female)
• Genitourinary (Male)
• Hematologic/Lymphatic/Immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin
15
16
8
Assigning E&M Code Levels Notes/Comments
• Categories of problems
• Minor or self-limited, stable, improving or
worsening – 1 point
• Established problem, stable – 1 point
• Established problem, worsening – 2 points
• New problem, no additional workup – 3 points
• New problem, workup planned – 4 points
17
9
Assigning E&M Code Levels Notes/Comments
• Management options
• Minimal – rest, superficial dressings or none
• Low – OTC medications, minor surgery without
risk factors, PT/OT, IV fluids without additives
• Moderate – Minor surgery with risk, major
surgery (elective) without risk, prescription drug
management, IV fluids with additives, closed
treatment of skeletal injury
Continued…
19
20
10
Assigning E&M Code Levels Notes/Comments
Summary
21
Summary (Continued)
22
11
Assigning E&M Code Levels Notes/Comments
Assessment
http://campus.ahima.org/audio/fastfactsresources.html
12
Assigning E&M Code Levels Notes/Comments
http://campus.ahima.org/audio/fastfactsresources.html
13
Appendix
Assessment Quiz
Continuing Education Credit and Compliance Sign-in Form
Certificate of Attendance and Quiz Completion
Quiz Answer Key
Assessment Quiz – Assigning Evaluation and Management Code Levels
To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete
this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a
copy of the completed quiz with your certificate of attendance. Do not send a copy to AHIMA.
1. For purposes of assigning evaluation and a. Either may be chosen for a specific patient.
management codes, an “established” patient is b. The physician must use the same set of
one who __________. guidelines for all patients.
a. has been seen by the provider before c. The 1995 guidelines are better to use for
b. has received face-to-face professional services general examinations.
from the provider or other member of the d. The guidelines are available for download on
same specialty in the same group within the the CMS website.
past three years
6. A description of what you are doing when a
c. has received professional services from the symptom occurs is considered to be
provider or other member of the same documentation of the __________ of the
specialty in the same group within the past complaint.
three years
a. context
d. has received face-to-face professional services
b. timing
from the provider or other member of the
same specialty in the same group within the c. location
past year d. None of the above
2. Time is the determining factor in assigning 7. True or false? Medical decision making is the
evaluation and management codes when most difficult of the three components of
__________. evaluation and management coding to quantity
a. counseling consumes more than half the time as it can be somewhat subjective.
of the visit a. True
b. the visit takes longer than usual b. False
c. any time that the provider feels that it is 8. An established problem that is worsening is
appropriate worth how many points in the medical decision
d. coding visits to patients in skilled nursing making process?
facilities a. 1 point
3. For purposes of assigning evaluation and b. 2 points
management codes, which of the following is not c. 3 points
considered counseling? d. 4 points
a. Advice re life style modification in combating 9. Elective major surgery without identified
effects of disease significant risk is considered to be a __________
b. Interactive psychotherapy level management option.
c. Discussion of medication administration and a. low
side-effects b. minimal
d. Provision of educational resources c. moderate
4. True or false? Only the physician may document d. high
history, physical examination and medical
10. True or false? In assigning risk, pick the lowest
decision making.
level in any of the three sections of data review,
a. True management options and nature of presenting
b. False problem.
5. Which of the following statements re selection of a. True
1995 vs. 1997 documentation guidelines is false? b. False
(answer choices are in next column)
Do not send a copy of completed quizzes to AHIMA. Please keep them with your certificate of attendance, for your
records. Be sure to complete and send the seminar sign-in sheet found on the next page of this resource book.
Sign below to certify that you have listened to this audio seminar and completed
the assessment quiz, to receive a total of 1 AHIMA CEU.
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Return this form to: Distance Education, AHIMA, 233 N. Michigan, Ste 2150, Chicago, IL 60601 Fax 312/233-1090
• Do not send completed Fast Facts Audio Seminar quizzes — keep them for your records •
Certificate of Attendance
Fast Facts Audio Seminar
Assigning Evaluation
and Management Code Levels
_____________________________________
Name
_____________________________________
AHIMA ID Number
_____________________________________
Date Attended
_____________________________________
Anne M. Willmore
Project Manager
Distance Education
Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA.
Please keep it with your certificate of attendance, for your records.