Consultation, Admission, newborn care, office visit
Types of Patient status
New, established, outpatient, inpatient
Written or verbal request from one provider/physician to another to obtain an opinion and/or advice about a diagnosis or management options.
attention to acute illness or injury that results in admission to a hospital
the evaluation and determination of care management of a newly born infant.
is a face to face encounter between a physician and a patient to allow for primary management of the patient's health care status.
a patient who has not received services from the same provider or a provider of the same specialty within the same practice for a period of three years
a patient who has been seen by the physician within the last 3 years, an important determination using E/M codes
one who has not been formally admitted to a health care facility or a patient admitted for observation
one who has been formally admitted to a health care facility.
The provision of similar services to the same patient by more than one physician or other qualified health care professional on the same day. no special reporting is required.
Transfer of care
the physical and verbal handing off of care from one health-care provider to another
discussion with patient and/or family
review of medical event's in patient's family
Key Components of E/M services
history, examination, and medical decision making
disease, condition, illness, injury, or other reason for encounter
5 types of presenting problems
Minimal, self-limited or minor, low severity, moderate severity, high severity.
may not require the presence of the physician, but service is provided under the physician's or other qualitfied health care professional's supervision.
Self-limited or minor
problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status
problem where risk of morbidity without treatment is low; there is little to now risk or mortality without treatment; full recovery without functional impairment is expected.
A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.
A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.
limited examination of the affected body area or organ.
Expanded problem focused
A limited examination of the affected body area or organ system and other symptomatic or related organ systems
An extended examination of the affected body area(s) and other symptomatic or related organ system(s).
A general multi-system examination or a complete examination of a single organ system. Its extent is based on age and risk factors identified.
Want to see the other 26 Flashcards in Chapter 15 Evaluation and Management Services?JOIN TODAY FOR FREE!