The McGraw-Hill Companies-INTRODUCTIONTO CPT：美国麦格劳-希尔公司介绍CPT.pptVIP

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The McGraw-Hill Companies-INTRODUCTIONTO CPT：美国麦格劳-希尔公司介绍CPT.ppt

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The McGraw-Hill Companies-INTRODUCTIONTO CPT：美国麦格劳-希尔公司介绍CPT

KEY TERMS category Chief complaint (CC) Consultation Consulting physician Contributory components Coordination of care Counseling Critical care Direct care E/M components Established patient Evaluation and management (E/M) codes Examination Face-to-face time Family history History History of present illness Key components Level of service (LOS) Medical decision making (MDM) New patient 1995 Documentation Guidelines 1996 Documentation Guidelines Observation Past history Place of service (POS) Presenting problem Preventive medicine Problem-oriented Professional services Referral Referring physician Review of systems Roll-up rule Social history Standby Time Unit/floor/time CODE ORGANIZATION E/M codes break down into categories and subcategories Categories – examples are: Office or outpatient services Hospital observation services Hospital Inpatient services Subcategories – examples are: New patient Established patient Discharge services See table 7.1 for the complete listing SELECTION PROCESS A standard set of questions used for determining the correct E/M code category: Who is the patient? What is the place of service? What is the patient’s status? What type of service is being provided? What level of service is being provided? WHO IS THE PATIENT? Determine whether the patient is new or established based on CPT E/M guidelines. A new patient: has not received any professional services from the physician within three years. has not received any professional services from another physician of the same specialty in the same group practice within three years. May have received professional services from another physician in the same group who is in a different specialty within three years. WHO IS THE PATIENT? An established patient: Has received professional services from the physician within the past three years Has received professional services from another physician of the same specialty in the same group practice within three years. Age categories Neonate (bi