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LESSON 4 EVAL. MAGMT
EVALUATION MANAGEMENT
| Question | Answer |
|---|---|
| What are the levels of Evaluation Management E/M services based on? | Documentation, key components and contributing factors. |
| Who must document the HPI in the medical record? | The physician |
| What is the difference between subjective and objective in the examination? | Subjective the patient gives the physician information regarding the problem. Objective is the findings observed by the physician during the examination. |
| What are the three elements of medical decision making? | Number of diagnosis or management options. Amount and/or complexity of data to review. Risk of complication or death if the condition goes untreated. |
| What is a consultation? | A written or verbal request from one provider/physician to another to obtain an opinion and/or advise. |
| Critical care codes are reported based on ? | The time the physician spends providing critical care to the patient. |
| When a physician performs a preventative care service, the extent of the exam is determined by ? | The age, gender, new patient, established patient, risk factor reduction and behavior change intervention. |
| What is the age of a neonate? | 28 days or younger. |
| What determines an established patient from a new patient? | A new patient is one who has not received services from the physician within 3 years. An established patient is one who has received services from a physician within 3 years. |
| What is the difference between an inpatient versus an outpatient status? | Inpatient is one who has formally admitted to the hospital fa. Out patient is one who receives emergency department services, but has not been admitted to the hospital. |
| What are the three factors of the evaluation management E/M codes? | Place of service, type of service, patient status. |
| What is a chief complaint? | Medical term to describe the primary problem or symptom. Why is patient here. |
| What is a modifier 25? | Modifier 25 is used to report evaluation management E/M services on a day when another service was provided. |
| Give examples of each history of Present Illness: | LOCATION: site of body, TIMING: when it happened, QUALITY: pain, sharp, CONTEXT: under what circumstances, SEVERITY: how intense, MODIFYING FACTORS: what makes it worse, ASSOCIATED SYMPTOMS; what else is happening, DURATION: how long, |
Created by:
Lizbeth Romo
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