Billing and Coding
return to: Iowa Otolaryngology Resident Handbook
see also: Nine minute video: Resident Education of Billing and Coding for Physician Services
|
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 |
|
|
|
|
|
|
|