- Evaluation and Management Coding Guide — (use this)
- HPI Table
- Table of Risk from the CMS
- Audit Sheet used by medical billing
cms.gov: SELECTING THE CODE THAT BEST REPRESENTS THE SERVICE FURNISHED (scroll down to find this section)
Doc on Patient Evaluation and Management Coding
CMS.gov page on Evaluation and Management Services
PFSH = Past medical history, family history, Social hx.
HPI – The numbers represent points. Points are things like onset, timing, etc. OPQRST-A that you include for every problem.
Clinic coding workflow (Recommended by new ped’s attending)
1) See the patient > 2) Code the Visit > 3) Then write the note to support the code.
This approach ensures that you always provide adequate documentation for the code you have chosen.
ROS – Counts the number of systems. For each system to count, you need to cover at least two points pertaining to that systems.
Modifier 25 : Used in two situations:
1) For procedures when you do them during a visit that also addresses other problems.
2) For a preventative visit that has other problems addressed in addition to the preventive exam.
An easy way to code new patient visits is to identify the code you will give if it was an established visit and then come down one level. Take a look at the Evaluation and Management Coding Guide above and see that a level four established patient has the same requirements as a level 3 new patient. The reasoning is that new patient visits get paid for more anyway.