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2023 CPT E/M coding

Terms and definitions for 2023 CPT evaluation and management (E&M) calculation

TermDefinition
Strong, smart, capable, mighty That's what we are.
A *specifically identifiable* procedure or service A procedure or service that is identified with a specific CPT code.
The 4 levels of medical decision-making (MDM) Straightforward Low Moderate High
Elements required for STRAIGHTFORWARD level of MDM 1 self-limited or minor problem. MINIMAL or no data review/analysis. MINIMAL risk of morbidity from additional diagnostic testing or treatment.
Problem A disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
Problem addressed When a problem is evaluated and treated at the encounter by the physician or other qualified healthcare professional reporting the service.
Minimal problem A problem that may not require the presence of the physician or other qualified HCP, but the service is provided under the physician's or other qualified HCP's supervision.
HCP Healthcare professional
Self-limited or minor problem A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
Stable, chronic illness A problem with an expected duration of at least 1 YEAR OR UNTIL THE DEATH of the patient.
Stable Defined by the specific treatment goals for an individual patient. A patient who is NOT at his or her treatment goal is not _____, even if the condition has not changed and there is no short-term threat to life or function.
Stable When the patient is at their treatment goal.
Acute, uncomplicated illness or injury Recent or new short-term problem with low risk for morbidity, for which treatment is being considered.
Acute, uncomplicated illness or injury Illness or injury with little or no risk of mortality with treatment, for which full recovery without functional impairment is expected.
Acute, uncomplicated illness or injury Illness or injury that is normally self-limited or minor but is not resolving consistent with definite prescribed course.
Acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care Recent/new short-term prob. w/low risk morbidity for which treatment is required. Little/no risk of mortality w/treatment, full recovery w/o functional impairment expected. Trtmt required is delivered in hospital inpatient or observation level setting.
STABLE, ACUTE illness Problem that is NEW OR RECENT for which TREATMENT HAS BEEN INITIATED. The problem is improved and, while resolution may not be complete, is stable with respect to this condition.
Chronic illness with exacerbation, progression, or side effects of treatment Chronic illness that is acutely worsening, poorly controlled, or progressing, with an intent to control progression and requiring additional supportive care or requiring attention or treatment for side effects.
Undiagnosed new problem with uncertain prognosis Problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
Acute illness with systemic symptoms An illness that causes systemic symptoms and has a high risk of morbidity without treatment. Systemic symptoms may not be general but may be single system.
Acute, complicated injury Injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and-or associated with risk of morbidity.
Chronic illness with SEVERE exacerbation, progression, or side effects of treatment SEVERE exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function Acute illness w/systemic symptoms, acute complicated injury, chronic illness or injury with exacerbation or progression or side effects of treatment, that poses a threat to life or bodily function IN THE NEAR TERM WITHOUT TREATMENT.
Acute or chronic illness or injury that poses a threat to life or bodily function Some symptoms may represent a condition that is SIGNIFICANTLY PROBABLE and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity
Analyze The process of using the data as part of the MDM.
Test Imaging, laboratory, psychometric or physiologic data.
Pulse oximetry For the purpose of data reviewed and analyzed, _____ ________ is not considered a test.
Lab panel A group of tests that is considered and counted as a single test.
Unique test Defined by the CPT code set, multiple results of the same ____ ____ count as one ____ ____. (I.e., serial blood sugars.)
Appropriate source A source that includes professionals who are not healthcare professionals but may be involved in the management of the patient (lawyer, parole officer, case manager, teacher). Does not include family or informal caregivers.
Risk The probability and/or consequences of an event.
Level of risk _____ __ ____ is based upon consequences of the problems addressed at the encounter when appropriately treated. Also includes MDM related to the need to initiate or forgo further testing, treatment, and/or hospitalization.
Morbidity State of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
Social determinants of health Economic and social conditions that influence the health of people and communities, such as food or housing insecurity.
Minor or major surgery Classification of surgery that is is based on the common meaning of such terms when used by trained clinicians, and not by a surgical package classification.
Elective or emergency surgery Describes the timing of a procedure when the timing is related to the patient's condition
Elective procedure A minor or major procedure that is typically planned in advance (scheduled for weeks later).
Emergent procedure A minor or major procedure that is typically performed immediately or with minimal delay to allow for patient stabilization.
Drug therapy requiring INTENSIVE MONITORING for toxicity A drug or therapeutic agent that has the potential to cause serious morbidity or death. _________ __________ is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.
Independent historian Someone who provides history in addition to that provided by patient unable to provide complete or reliable history (due to developmental stage, dementia, psychosis) or because confirmatory history judged necessary.
Independent historian The ___________ _________ requirement is met in a case where there may be conflict or poor communication between multiple historians and more than one historian is needed.
Independent historian The ___________ _________ requirement does not include translation services.
Independent The _____ history does not need to be obtained in person, but does need to be obtained directly from the historian providing the ______ history.
The 4 levels of Elements of MDM work performed & analyzed during the encounter are… Minimal or none, Limited, Moderate, Extensive
Prescription drug management ____________ ____ __________ is based on documented evidence that the provider has evaluated the patient's medications as part of a service.
Prescription drug management Simply listing current medications is not considered ____________ ____ __________.
Prescription drug management ____________ ____ __________ may be a prescription being written or discontinued, or a decision to maintain a current medication or dosage.
Brain pain What you get after studying too many flash cards. ;^)
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