Table of Contents
What are the three components in determining the code selection when billing?
3 Key Components of E/M Coding: History, Exam, Medical Decision Making. Evaluation and management coding is a type of medical coding used by physicians and certain other healthcare providers to report their services as part of medical billing.
What are the key components of the office and other outpatient evaluation and management coding select all that apply?
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity.
What are the key components of the office and other outpatient evaluation and management coding?
What are the three key components that are present in every patient case except?
E/M coding
| Question | Answer |
|---|---|
| The three key components that are present in every patient case except counseling encounters and that enable the coder to choose the appropriate level of service are: 1. history 2. ___________________ 3. medical decision-making | examination |
What are the key components to be checked when performing a coding audit?
Coding Audits: A Compliance Necessity
- An official examination and validation of the medical record documentation and coding.
- A systematic review of the medical record, including the clinical coding, along with a written analysis and report of findings.
Which of the following are considered key components when assigning a level of E M services select the three 3 correct answers?
Select the appropriate code based on the three key components. when documenting Evaluation and Management (E/M) services, providers often focus only on the three (3) key components: history, examination and medical decision making.
When choosing an em code and all three key components are not met do you select the lower level or higher level?
You must choose your code based on the lowest documented component because you have to meet (or exceed) the requirements for all three components.
What are the five elements to the basic format of the services found in the e/m section?
According to the E/M, there are five elements to the basic format of the services found in the E/M section. The first is the unique code number, the second is the place/type of service, the third is the content of the service, and the fourth is the nature of presenting problem.
When choosing an E M code and all three key components are not met do you select the lower level or higher level?
For new patient rest home visit E/M codes that require you to meet or exceed three out of three key components (99324-99328), you have to code based on the lowest level component from the encounter. Suppose a visit included a comprehensive history, an expanded problem focused exam, and MDM of moderate complexity.
When choosing an E M code and all three key components are not met do you select the lower level or higher level why?
For new patient rest home visit E/M codes that require you to meet or exceed three out of three key components (99324-99328), you have to code based on the lowest level component from the encounter.
What are three goals you would set before a coding audit?
There are many goals in an audit: Identify errors in provider documentation. Identify inefficiencies in payer reimbursement. Determine usage of incorrect medical codes, such as use of deleted or modified codes.
What are the two types of coding audits?
Coding Outcomes Based on Method The two main coding audit methodologies utilized to measure ICD-10 accuracy—per code and per record—focus on assessing coding quality. Results can vary widely depending on the process.
What are the three key elements required when assigning a Problem Oriented E M service?
The three key components (history, examination, and medical decision making) are required for most E/M codes.