Abstracting the Level of Service with E/M Codes Read the mini medical record of
ID: 240000 • Letter: A
Question
Abstracting the Level of Service with E/M Codes Read the mini medical record of each patient's encounter and answer the following questions 1. OFFICE Gender: F Age: 48 Status: Established Chief Complaint: annual preventive care visit History: pure hypercholesterolemia Examination: comprehensive preventive care exam Medical Decision Making: Cholesterol seems to be well controlled. No new problems. a. In what setting was the service provided?-office b. What type of service was provided? C. Is the patient new or established? d. What code range is applicable for this type of encounter? e. What is the title of the subcategory of the range of codes? f. What criteria are used to determine the level of service? g. What patient information meets these criteria? h. What CPT code(s) is/are assigned to this patient's claim? 2. INPATIENT HOSPITAL Gender: M Age: 25 Chief complaint: patient admitted by me for hematuria. History: Detailed. Extended HPl, extended ROS, pertinent PFSH Examination: comprehensive GU exam Medical Decision Making: moderate complexity a. In what setting was the service provided? b. What type of service was provided? c. Is the encounter initial or subsequent? d. What code range is applicable for this type of encounter? e. What is the title of the subcategory of the range of codes? f What criteria are used to determine the level of service? g What level of examination was performed? h. What is the complexity of the medical decision making? i. -How much time was spent in counseling and coordination of care? i What CPT code(s) is/are assigned to this patient's claim? United States) @Explanation / Answer
1.
a.In what setting was the service provided? OFFICE
b.What type of service was provided? Occupation-related health service-(This include preventive examinations and health condition assessments, which are used to evaluate the fitness of an individual to perform the task required of them by their respective job.)
c.Is the patient new or established? ESTABLISHED.(An established patient is one who has received professional services from the physician/qualified health professional of same speciality within the past 3 years whereas, A new patient is one who has not received any professional services yet.)
d.What code range is applicable for this type of encounters? Z00.00 is applicable to adult patients aged 15-124 years. Encounter for general adult examination w/o abnormal findings.
h. What CPT code is assigned to this patient’s claim? 99381-99397