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Billing and Coding

last modified on: Wed, 01/24/2018 - 13:36

Billing and Coding

return to: Iowa Otolaryngology Resident Handbook

 see also: Nine minute video: Resident Education of Billing and Coding for Physician Services


E&M coding Reference Card  

Microsoft Office document iconhand held card.doc

H&P- Template for Dictation of New Visits, Admits, and Consults

 

REASON FOR NEW/CONSULT/ADMIT

Why the patient is being seen-Required

HISTORY OF PRESENT ILLNESS

For the HIGHEST levels, 4 elements are required:  location,quality,severity, duration of symptoms, timing, context, modifying factors, associated signs and symptoms

PAST MEDICAL HISTORY

Required for high levels

ALLERGIES

Count as one element in Review of Systems

SOCIAL HISTORY

Required for high levels

FAMILY HISTORY

Required for high levels, positive or negative in family members.

MEDICATIONS

 

REVIEW OF SYSTEMS

For the HIGHEST levels, 10 systems must be documented-Required.  May list pertinent positive or negatives and “ALL OTHERS NEGATIVE”.  Constitutional, Eyes, Ears/Nose/Mouth/Throat, CV, Resp, GI, GU, Musc, Skin, Neuro, Psych, Endo, Hem/Lymph, All/Imm

PHYSICAL EXAMINATION

For the HIGHEST levels, 8 organ systems are required:  Constitutional, Eyes, Ears/Nose/Mouth/Throat, CV, Resp, GI, GU, Musc, Skin, Neuro, Psych, Hem/Lymph

LABS/RADIOLOGICAL REVIEW

X-Ray Films/ CT Scan Reviewed.  Used for complexity

IMPRESSION

Used for complexity

PLAN

List the plans:  labs, x-rays, ct’s, surgery, etc

Reviewed 10-05-06

 

 

 

 

 

 

REASON FOR NEW/CONSULT/ADMIT

HISTORY OF PRESENT ILLNESS

4

Location

Severity

Timing

Modifying Factors

Quality

Duration

Context

Associated Signs & Symptoms

 

REVIEW OF SYSTEMS

10

Constitutional

Card/Vasc

GU

Neuro

Hem/Lymph

Eyes

Resp

Musculo

Psych

All/Imm

Ears/Nose/Mouth/Throat

GI

Skin

Endo

 

 

PFSH (Past, Family and Social History)

ALL

Past Medical History

Family History

Social History

 

PHYSICAL EXAMINATION

8

Constitutional

Card/Vasc

GU

Neuro

Eyes

Resp

Musculo

Psych

Ears/Nose/Mouth/Throat

GI

Skin

Hem/Lymph

 

 

 

 

 

 

 

 

 

New Patient or Consult

 

LEVEL 1

LEVEL 2

LEVEL 3

LEVEL 4

LEVEL 5

History

PF

EPF

D

C

C

 

 

 

 

 

 

HPI

1-3 elements

1-3 elements

4 HPI elements Or 3 Chronic Illnesses

4 HPI elements Or 3 Chronic Illnesses

4 HPI elements Or 3 Chronic Illnesses

 

 

 

 

 

 

ROS

0 systems

1 system Pertinent to Problem

2-9 systems

10 or more systems

10 or more systems

 

 

 

 

 

 

PFSH

0 elements

0 elements

1 or 2 P,F or S

all 3

all 3

 

 

 

 

 

 

Exam

PF

EPF

D

C

C

 

System related to problem

2-4 systems

5-7 systems

8 or more systems

8 or more systems

 

 

 

 

 

 

Complexity

SF

SF

L

M

H

 

Straightforward

Straighforward

Low

Moderate

High

 

 

 

 

 

 

 

Established Outpatient

 

LEVEL 1

LEVEL 2

LEVEL 3

LEVEL 4

LEVEL 5

History

 

PF

EPF

D

C

 

 

 

 

 

 

HPI

Minimal Problem-may not require presence of  physician

1-3 elements

1-3 elements

4 HPI elements Or 3 Chronic Illnesses

4 HPI elements Or 3 Chronic Illnesses

 

 

 

 

 

 

ROS

 

0 systems

1 system Pertinent to Problem

2-9 systems

10 or more systems

 

 

 

 

 

 

PFSH

 

0 elements

0 elements

1 history

2 or 3 history areas

 

 

 

 

 

 

Exam

 

PF

EPF

D

C

 

 

System related to problem

2-4 systems

5-7 systems

8 or more systems

 

 

 

 

 

 

Complexity

 

SF

L

M

H

 

 

Straighforward

Low

Moderate

High