Interview Question for E&M service
What is Place of services ?
The place of service and service type are defined by the location where the face-to-face encounter with the patient and/or family/caregiver occurs. For example, service provided to a nursing facility resident brought to the office is reported with an office or other outpatient code.
What is new patient and established patient ?
A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
What is Principal diagnosis ?
Principal diagnosis is the primary condition or disease identified by a healthcare provider as the main reason for a patient's encounter or hospitalization.
Is new or established patient exist in ED department like as E&M ?
No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
Who are qualified healthcare professional ?
A “physician or other qualified health care professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service.
Who are Clinical staff ?
A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service.
What are initial and subsequent services ?
An initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.
A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the admission and stay.
How to report separte service performed along with E&M ?
Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately. The E&M service should report with Modifier 25.
In how many different ways you can report E&M service ?
Select the appropriate level of E/M services based on the following:
1. The level of the MDM as defined for each service, or
2. The total time for E/M services performed on the date of the encounter
What are the guideine for selecting level of service based on Medical decision making (MDM) ?
Four types of MDM are recognized: straightforward, low, moderate, and high. The concept of the level of MDM does not apply to 99211, 99281. MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. MDM is defined by three elements.
The elements are:
1.The number and complexity of problem(s) that are addressed during the encounter.
2.The amount and/or complexity of data to be reviewed and analyzed.
These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.
Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered.
These considerations must be documented. Data are divided into three categories:
● Tests, documents, orders, or independent historian(s).
(Each unique test, order, or document is counted to meet a threshold number.)
● Independent interpretation of tests (not separately reported).
● Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source (not separately reported).
3.The risk of complications and/or morbidity or mortality of patient management .
This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared decision making with the patient and/or family.
For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.
What is the meaning of "Problem" in MDM table ?
Problem: A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
What is the meaning of "Minimal problem" in MDM table ?
Minimal problem: A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281).
What does "Self limited or Minor problem" indicate in MDM table ?
Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
What does "stable,chronic illness" indicate in MDM table ?
Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition).
"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
What does "acute, uncomplcated illness or injury" indicate in MDM table ?
Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally selflimited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.
What is meaning of "stable , acute illness" in MDM table?
Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
What is chronic illness with severe exacerbation ?
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
What is unique test and unique source indicated in MDM table ?
A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count.
A unique source is defined as a physician or other qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.
What is independent historian ?
Independent historian(s): An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It does not include translation services. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.
What is Morbidity ?
Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
What is Outpatient or Inpatient ?
Outpatients are the people who visit a hospital for treatment but are not admitted. These patients may stay at the hospital for few hours or even overnight. Since outpatient visits are short-term, outpatient coding is relatively less complex than inpatient coding.
Inpatients are those people who have been formally admitted to the hospital under a doctor’s order.The patient must spend more than 24 hours at the hospital.
What are the difference between Review of systems and the physical examination sections of the H&P mentioned by the physcian ?
The ROS is a systematic inquiry of the patient's symptoms and signs, organized by body systems. The physician asks the patient a series of questions to obtain information about any current or past symptoms or medical conditions. The ROS includes questions about the patient's general health, such as fatigue, fever, or weight loss, as well as specific symptoms related to each body system, such as chest pain, shortness of breath, or abdominal pain.
The ROS is a comprehensive assessment of the patient's health status and helps the physician to identify any potential health problems that may require further evaluation.
The PE is a physical examination of the patient's body, performed by the physician. The PE includes a thorough inspection, palpation, percussion, and auscultation of each body system. The physician examines the patient's vital signs, such as blood pressure, heart rate, and respiratory rate, and evaluates the patient's overall appearance, skin, and musculoskeletal system. The PE is a hands-on assessment of the patient's physical health and helps the physician to identify any abnormalities or physical findings that may require further evaluation.
What is social determinates of health ?
Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.
What is Elective and Emergency procedure mentioned in MDM table ?
Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.
What is major and minor surgery ?
According to medicare, a major surgery has a global period of 90 days and minor surgery has a global period of either 10 or 0 days.
What is undiagnosed new problem with uncertaing prognosis ?
Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
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