Briefing Evaluation and Management “Hot Spots”：介绍评价和管理的“热点”.ppt

* Time When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time MAY be considered the key or controlling factor to qualify for a particular level of E/M services* In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service**. The time-in/time-out or total time spent counseling and/or coordinating care must be documented The description of counseling/coordination of care needs to be documented *2010 CPT **1997 Documentation Guidelines for Evaluation and Management Services * Questions ? * Track x – xxx day – 0000-0000 * Chief complaint…why are you here? * Chronological description of the development of the patient’s illness from the first sign and/or symptoms or from the previous encounter to the present encounter. It includes as we know, the following elements. Location- specific site of complaint Quality-description of sensations Severity-describes the severity Duration-how long they’ve had the symptoms Timing-refers to the intervals of symptoms Context-refers to how symptoms began or how they occur Modifying factors-describes what measures patient takes to make symptoms less pronounced Associated signs and symptoms-signs and symptoms patient feels are related to complaint * Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem/s. The second DG, for the extended HPI, talking about the status of at least three chronic or inactive conditions – the key in this statement is “status of”. That means we need to see the providers q & a on the chronic conditions documented. E.g., how have your self monitored BPs been since I last saw you? (HTN), have you had to use your emergency inhalers? (asthma)…th