Hathaway 1

Jon Hathaway, MD PhD
4:00 - 5:00 pm Feb 1, 2013
Coding Made Easy

Coding for Cash
And to avoid the penitentiary
Jon K. Hathaway, MD, PhD
Objectives
Review
Coding Documentation
Guidelines
Review the Global Package
Discuss ICD-9 and ICD-10
Review Inpatient coding (time
permitting).
2013 MSACOG Snow Meeting
4:00 - 5:00 pm Feb 1, 2013
How does your office determine

coding level for E&M visits?
0%
0%
0%
er
0%
So
5.
0%
O
th
4.
.
eo
ne
in
m
y.
T
he
..
E
M
R
co
de
s.
..
I
alw
ay
sb
ill
..
.
3.
co
de
it
2.
I code it.
Someone in my
office codes it.
The EMR codes it.
I always bill a
99213 (whatever
that is).
Other
1.
Purpose of Coding
To
$tandardize the de$cription of

the patient$ $ymptom or di$ea$e
proce$$.
To allow for retro$pective re$earch
to evaluate outcome$,
intervention$, etc.
To evaluate quality of care.
To evaluate what procedure$ are
being performed for which
diagno$e$.
4:00 - 5:00 pm Feb 1, 2013
Types of Codes
ICD-9/10:
Identifies
diseases or symptoms.
International
Classification of
Disease.
CPT-4: Identifies
procedures performed.
Current Procedural
Terminology.
ICD
ICD
does not allow you to code for

rule out, suspected or Probable
conditionsindicate a symptom if
you dont have a specific diagnosis.
Use only current conditions that are
the reason for the visit (if you dont
treat or address the HTN or
hypothyroidism, then dont code it).
4:00 - 5:00 pm Feb 1, 2013
Evaluation & Management

coding (E&M)
Types
of visits
Problem visit
New
Established (seen by practice or Dr in last 3 years)
Consultation
Preventative
New
Established
Age
Ranges
What is the definition of

outpatient?
1.
2.
3.
4.
Anyplace that isnt

inpatient-duh!
Only outpatient office
buildings not attached
to a hospital.
Only private office
space, attachment to
hospital unimportant.
Only private office
space and emergency
rooms, everywhere
else is inpatient.
0%
1
0%
2
0%
3
0%
4
4:00 - 5:00 pm Feb 1, 2013
Elements of a Visit
History
Exam
Assessment
Plan
Elements of a Visit
History
Chief Complaint
History of Present Illness (HPI)
Past Medical, Family and Social Hx (PSFH)
Review of Systems (ROS)
Examination
1995 & 1997 guidelines
Medical Decision Making

Number of Diagnoses
Amount/Complexity of Data or Mortality
Risk of Complications or Morbidity
4:00 - 5:00 pm Feb 1, 2013
Elements of a Visit
History
Chief Complaint (reason for the visitdoesnt have to be a

complaint)
HPI:
Elements
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
2 types brief or extended.
Brief has 1-3 elements

Extended has 4+ elements
Extended can also be 3 chronic or inactive conditions.
Mrs. A c/o vaginal bleeding, heavy (could use pad count),

lasting 5-7 days every 28 days for the last 6 months.
Seem to be better when on OCPs.
History
Level
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded PF
Brief
None
Detailed
Extended
2-9
Comprehensive
Extended
10+
2+
4:00 - 5:00 pm Feb 1, 2013
Elements of a Visit
ROS
12 areas: Constitutional, Eyes, ENT, CV,

Pulm, GI, GU, MS, Integumentary,
Neuro, Psych, Endo, Heme/lymph,
Allergy.
One system: Expanded Problem
Focused
2-9 systems: Detailed
10+ systems: Comprehensive
Any problems with your bowels or
bladder?
Elements of a Visit
History
PFSH (Past, Family, Social History)

One
element: Pertinent
2+: Complete
4:00 - 5:00 pm Feb 1, 2013
History
Mrs.
A c/o amenorrhea for 6

months, has been irregular since
age 18 when she gained a lot of
weight. Normal menses when on
OCPs. Also c/o facial hair and a
dirty neck.
No Bowel or Bladder Issues
Past Medical History significant for
obesity and infertility despite
trying.
History
Level
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded PF
Brief
None
Detailed
Extended
2-9
Comprehensive
Extended
10+
2+
4:00 - 5:00 pm Feb 1, 2013
Moving On
Exam
1995
Guidelines: Not good for basic

OB/GYN so fought for new
guidelines!!
1997 Guidelines: EXCELLENT!!
4:00 - 5:00 pm Feb 1, 2013
Elements of an Exam
Constitutional:
3 vitals (BP, Pulse, Resp, Temp, Ht, Wt)

General Appearance
GI:
Exam of Abdomen (masses, tenderness)

Exam of Liver and Spleen
Occult blood (if indicated)
Hernia
Elements of an Exam
GU
Breast Exam
Digital Rectal Exam
External Genitalia
Meatus: location, prolapse, lesions.
Urethra: masses, tenderness, scarring.
Bladder: fullness, masses, tenderness.
Vagina: support, estrogen, discharge, lesions
Cervix: appearance, lesions, discharge
Uterus: size, contour, mobility, position, support
Adnexa: mass, tenderness, organomegaly
Anus/Perineum
10
4:00 - 5:00 pm Feb 1, 2013
Elements of an Exam
Neck:
Thyroid
General Exam
Respiratory
Effort
Auscultation
CV
Auscultation
Peripheral Vascular System (varicosities, swelling, pulses,
edema, tenderness)
Lymphatic
Skin
Neuro/Psych
Palpation of lymph nodes: neck, axillae, &/or groin.

Inspection and Palpation (rash, lesion, ulcer)
Orientation
Mood/Affect
Exam
Four
Types
Problem Focused: 1-5 elements

Expanded PF: 6-11 elements
Detailed: 12+ elements
Comprehensive: Lets Talk.
11
4:00 - 5:00 pm Feb 1, 2013
Comprehensive Exam
All Consitutional: 3 vitals, general appearance.

All GI: Exam, liver/spleen, occult blood, hernia
Any 7 GU elements
One element from:
Neck:
Thyroid
General Exam
Respiratory
CV
Effort
Auscultation
Auscultation
Peripheral Vascular System (varicosities, swelling, pulses, edema, tenderness)
Lymphatic
Palpation of lymph nodes: neck, axillae, &/or groin.
Skin
Inspection and Palpation (rash, lesion, ulcer)
Neuro/Psych
Orientation
Mood/Affect
1995 Guidelines
Body Areas
Head
Neck
Chest/Breast
Abdomen
Genitalia/Buttocks
Back/Spine
Extremities
Organ Systems
Constitutional
Psych
Skin
ENMT
Eyes
Neuro
Respiratory
GI
Heme/Lymph
Musculoskeletal
GU
Cardio
12
4:00 - 5:00 pm Feb 1, 2013
1995 Guidelines
Problem Focused
1 element
Expanded PF
2-4 elements
Detailed
5-7 elements
Comprehensive
8+ elements
All of the following body parts get

bigger with age except?
1.
2.
3.
4.
Feet
Nose
Ears
Genitalia
0%
1
0%
2
0%
3
0%
4
13
4:00 - 5:00 pm Feb 1, 2013
Here Comes the Hard Part
Straightforward
Low Complexity
Moderate Complexity
High Complexity
Number of Diagnoses or Management Options

Amount or Complexity of Data to Review
Risk of Complications or Morbidity/Mortality

Diagnoses
Minimal
Limited
Multiple
Extensive
Data
Minimal
Limited
Moderate
Extensive
Risk
Minimal
Low
Moderate
High
Straight
Forward
Low
Complexity
Moderate
Complexity
High
Complexity
14
4:00 - 5:00 pm Feb 1, 2013
Number of Diagnoses
Self-Limited or Minor:
Established Problem, stable:
Established Problem, worsening:
New Problem, No additional w/u:
New Problem, additional w/u:
Minimal:
Limited:
Multiple:
Extensive:
1
2
3
4
1
1
2
3
4
point
point
points
points
points
point
points
points
points
Amount/Complexity of Data
Review/Order lab tests or procedure:

Radiology or Medical arena
Discussion of diagnostic test results

w/ performing physician:
Decision to obtain old records &/or
Obtaining history from someone other than patient:
Review and summary of old records &/or
Obtaining history from someone other than patient &/or
Discussion of case with another provider:
Independent visualization of image/tracing/specimen:
Minimal:
Limited:
Multiple:
Extensive:
1
2
3
4
1 point
1 point
2 points
2 points
2 points
point
points
points
points
15
4:00 - 5:00 pm Feb 1, 2013
Level of Risk
Minimal: One self-limited or minor problem/CXR/superficial dressing.

Cold, insect bite, tinea corporis.
UA, Wet Mount, blood tests, U/S ordered
Rest, Ace bandage
Low: One stable chronic illness/superficial needle bx/OTC Rx.

Acute, uncomplicated illness or injury
Arterial blood tests, Imaging studies with contrast (SIS)
Minor surgery with no identified risk factors, IV fluids
Moderate: One or more chronic illnesses w/ mild exacerbation,

progression or side effects/diagnostic endoscopies w/ no identified risk
factors.
New problem with uncertain prognosis (breast lump), 2 stable chronic illness
(DM and HTN), Acute illness w/ systemic sx, acute, complicated injury
Fetal STRESS test, CV imaging, Deep needle or incisional bx (including
culdocentesis
Minor surgery with risk factors, Elective major surgery w/o risk factors,
Management of prescription drugs, IV fluids with additives
High: Acute or Chronic illnesses or injuries that pose a threat to life or

bodily function/diagnostic endoscopies w/ identified risk
factors/Emergency major surgery.
Abrupt change in neuro status

CV imaging with risk factors, Dx endoscopies with risk factors
Elective or emergency major surgery with risk factors, drug therapy requiring
intensive monitoring for toxicity.
Level of Risk
Minimal: One self-limited or minor

problem/CXR/superficial dressing.
Wet Mount
Rest
Low: One stable chronic illness/OTC Rx.
Imaging studies with contrast (SIS)

Minor surgery with no identified risk factors
IV fluids
Vaginitis
Renewal of HRT/OCP
16
4:00 - 5:00 pm Feb 1, 2013
Level of Risk
Moderate: One or more chronic illnesses w/ mild exacerbation,

progression or side effects/diagnostic endoscopies w/ no
identified risk factors.
New problem with uncertain prognosis (breast lump)

Irregular bleeding
Diagnostic endoscopies w/ no identified risk factors
Minor surgery with risk factors
Elective major surgery w/o risk factors
Management of prescription drugs
IV fluids with additives
High: Acute or Chronic illnesses or injuries that pose a threat to

life or bodily function/diagnostic endoscopies w/ identified risk
factors/Emergency major surgery.
Dx endoscopies with risk factors

Pelvic Pain
Multiple complaints
Elective or emergency major surgery with risk factors
Drug therapy requiring intensive monitoring for toxicity.

Number of Diagnoses or Management
Options
Amount or Complexity of Data to
Review
Risk of Complications or
Morbidity/Mortality
Only need 2 out of 3!!
17
4:00 - 5:00 pm Feb 1, 2013

Diagnoses
Minimal
Limited
Multiple
Extensive
Data
Minimal
Limited
Moderate
Extensive
Risk
Minimal
Low
Moderate
High
Straight
Forward
Low
Complexity
Moderate
Complexity
High
Complexity
When was insemination without

intercourse discovered?
ud
alm
T
0%
64
)
0%
(1
7
8B
C)
s(
9
ra
nu
So
0%
(2
00
AD
)
0%
co
bi
4.
Ja
3.
bs
(1
50
0A
D)
2.
Soranus (98BC)
Talmud (200AD)
Arabs (1500AD)
Jacobi (1764)
A
ra
1.
18
4:00 - 5:00 pm Feb 1, 2013
Putting it all together
New Patient
History
Exam
Medical Decision
Making
Level 1
Problem Focused
Problem Focused
Level 2
Expanded Problem
Focused
Level 3
Detailed
Detailed
Level 4
Comprehensive
Comprehensive
Moderate Complexity
Level 5
Comprehensive
Comprehensive
High Complexity
Straight Forward
Expanded Problem Straight Forward

Focused
Low Complexity
Established Patient: Only Need 2 of 3!!

History
Exam
Level 2
Problem Focused
Problem Focused
Level 3
Expanded Problem
Focused
Level 4
Detailed
Detailed
Level 5
Comprehensive
Comprehensive
Medical Decision
Making
Level 1
Straight Forward
Expanded Problem Low Complexity

Focused
Moderate Complexity
High Complexity
19
4:00 - 5:00 pm Feb 1, 2013
Initial Consultation
History
Exam
Medical Decision
Making
Level 1
Problem Focused
Problem Focused
Level 2
Expanded Problem
Focused
Level 3
Detailed
Detailed
Level 4
Comprehensive
Comprehensive
Moderate Complexity
Level 5
Comprehensive
Comprehensive
High Complexity
Straight Forward
Expanded Problem Straight Forward

Focused
Low Complexity

Time-based
Billing
New Patient Established
Consultation
Level 1
10
15
Level 2
20
10
30
Level 3
30
15
40
Level 4
45
25
60
Level 5
60
40
80
20
4:00 - 5:00 pm Feb 1, 2013
Preventative Visits
Requirements based on age.

Payment for Hx and PE only (no MDM)
No specified elements of the exam.
Must document a multisystem exam.

For us includes breast and pelvic +/- Pap smear.
No need for CC or HPI.

Includes counseling such as contraception, safety,
need for screening tests, BSE, vaccines, etc.
Can bill for problem-based service if provided at
the same time (and documentation supports this).
May not get paid though.

ACOG suggests billing whichever takes the most time.
Can also break up the visit into two visits.
Patient may have a copay for E&M visit.
Most payers will not pay for 2 annual exams in

one year.
Medical Students
Any contribution and participation of a student to the

performance of a billable service must be performed in the
physical presence of a teaching physician or resident in a
service that meets teaching physician billing requirements
(other than the review of systems [ROS] and/or past, family,
and/or social history [PFSH], which are taken as part of an E/M
service and are not separately billable). You, the student, may
document services in the medical record; however, the
teaching physician may only refer to your documentation of an
E/M service that is related to the ROS and/or PFSH. The
teaching physician may not refer to your documentation of
physical examination findings or medical decision making in
his or her personal note. If you document E/M services, the
teaching physician must verify and redocument the history of
present illness and perform and redocument the physical
examination and medical decision making activities of the
service.
21
4:00 - 5:00 pm Feb 1, 2013
Who first recorded that

intercourse was necessary for
pregnancy?
H
ip
po
cr
4.
0%
0%
0%
0%
G
al
en
(2
00
AD
)
3.
A
ris
to
tle
(3
50
...
S
or
an
us
(9
8B
C)
2.
Hippocrates
(400BC)
Aristotle
(350BC)
Soranus (98BC)
Galen (200AD)
at
es
(4
...
1.
Any Questions?
22
4:00 - 5:00 pm Feb 1, 2013
CHIEF COMPLAINT:
Chronic pelvic pain. The patient is referred to Dr. X for an evaluation of her pelvic pain.
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 22-year-old Caucasian

female G zero whom I have been following in the clinic for several visits now
who has a history of longstanding chronic pelvic pain. Occurs most days and lasts all day. Stabbing mostly. Mainly located
behind the symphysis pubis. No relief with voiding or BM. Non-cyclical. +dyspareunia.
ROS: No Bladder or Bowel problems except GERD.
PAST MEDICAL HISTORY:
Significant for gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Tonsillectomy, adenoidectomy in 2007, as well as,

diagnostic laparoscopy in 05/2008.
GYNECOLOGIC HISTORY: The patient does have a history of abnormal Pap smear in
04/2008 which I believe was a low grade squamous intraepithelial lesion. She
followed up for colposcopy and had no procedures. Menarche onset at age 16,
every 28 days lasting up to five days with moderate flow, however, associated
with significant dysmenorrhea. The patient currently is on the Alesse birth
control pills with continued cramping. The patient is sexually active. Has a
positive history of Chlamydia and PID 01/2008.
SOCIAL HISTORY: Negativex3. She does have a boyfriend. Negative tobacco and
illegal drugs. The patient admits to occasional social drinking a drink
approximately twice a month.
FAMILY HISTORY:
Noncontributory.
What is the History Level?
4.
PF
0%
nd
e
Ex
pa
Pr
ob
le
m
Fo
cu
se
...
0%
0%
0%
et
ai
le
d
om
pr
eh
en
si
ve
3.
2.
Problem
Focused
Expanded PF
Detailed
Comprehensive
1.
23
4:00 - 5:00 pm Feb 1, 2013
PHYSICAL EXAMINATION:
GENERAL:
LUNGS:
On examination 150 pounds, blood pressure 106/70, Pulse 72.
NAD. No anxiety.
Clear to auscultation bilaterally.
CARDIOVASCULAR:
ABDOMEN:
Regular rate and rhythm, no murmurs, rubs or gallops.
Soft, nontender, nondistended.
GENITOURINARY: External genitalia within normal limits. Vaginal wall, urethra

and anus normal. Pelvic examination a small, anteverted, mobile uterus with
normal adnexal examination. No acute tenderness to palpation.
The patient's hemoglobin in 05/2008 12.2 and hematocrit of 36. Last
gonorrhea, chlamydia cultures 10/10/2008 both negative. The patient did have an
ultrasound done in 11/2008 at which point the uterus measures 6.7 x 3.4 x 4.7
cm, right and left ovaries within normal limits. The right ovary contained a
simple cyst measuring 2.2 x 1.1 x 1.4 cm, left ovary was within normal limits.
There was free fluid seen around both ovaries sounds.
What is the Physical Exam?
4.
PF
0%
nd
e
Ex
pa
Pr
ob
le
m
Fo
cu
se
...
0%
0%
0%
et
ai
le
d
om
pr
eh
en
si
ve
3.
2.
Problem
Focused
Expanded PF
Detailed
Comprehensive
1.
24
4:00 - 5:00 pm Feb 1, 2013
ASSESSMENT/PLAN: The patient is a 22-year-old Caucasian female G0 with

troubling psychiatric history, as well as, continued vague, fluctuating
complaints of pelvic pain, possibly component of a gastrointestinal trouble.
I discussed with the patient expectant management versus DepoProvera. She would like to try depoprovera. I would like her to be evaluated
by Dr. X. The patient was very open to the idea of seeing Dr. X. Given the
findings on the ultrasound of fluid around the ovaries, a repeat ultrasound may
be useful should she not improve here in the meantime. The
examination does not support an abscess or tubo-ovarian process at this point.
Medical Decision Making?
St
ra
ig
h
0%
0%
ig
h
0%
Lo
tfo
rw
ar
..
0%
4.
te
3.
od
er
a
2.
Straightforward
Low
Moderate
High
1.
25
4:00 - 5:00 pm Feb 1, 2013
What is the overall code?
0%
0%
0%
ve
l5
ve
l2
0%
Le
Le
ve
l1
0%
Le
5.
ve
l4
4.
Le
3.
1
2
3
4
5
ve
l3
2.
Level
Level
Level
Level
Level
Le
1.
Phew!!
So
who really cares and can you get

away with a few incorrect codes?
Im just too tired to worry about this
and so I just code a level 2 visit for
everything (this will cost you more
than $50K/year).
ARRGGHH!!
26
4:00 - 5:00 pm Feb 1, 2013
RVU differences
Established
Patient
99212
OUTPATIENT VISIT, RET
0.45
99213
0.67
99214
1.10
99215
OUT-PATIENT VISIT, RET
1.77
New
Patient
99201
OUT PATIENT VISIT NEW
0.45
99202
OUTPATIENT VISIT NEW
0.88
99203
OUTPATIENT VISIT NEW
1.34
99204
OUT-PATIENT VISIT NEW
2.00
99205
OUT PATIENT VISIT NEW
2.67
Rough estimate of Medicare RVU= $37.

Private Insurance RVU= $60.
Besides humans, what other

animal has sex for pleasure
only?
0%
hi
n
0%
D
ol
p
0%
an
t
P
or
cip
0%
D
og
s
0%
in
es
5.
ep
h
4.
ps
3.
El
2.
Porcipines
Chimps
Elephants
Dogs
Dolphins
C
hi
m
1.
27
4:00 - 5:00 pm Feb 1, 2013
ICD-10
Was
supposed to start October 1,

2013 but was pushed back to
October 1, 2014.
Many codes will have the same name
but there will be some differences
especially for OB.
Currently a freeze on ICD-9 changes.
ICD-10
28
4:00 - 5:00 pm Feb 1, 2013
ICD-10
ICD-9
Molar Pregnancy:
ICD-10
Molar Pregnancy
630 Hydatidiform mole
Trophoblastic disease
NOS
Vesicular mole
O01.0 Classical
hydatidiform mole
O01.1 Incomplete and
partial hydatidiform
mole
O01.9 Hydatidiform
mole, unspecified
ICD-10
ICD-9
631 Other abnormal
product of conception
Blighted ovum
Mole:
NOS
carneous
fleshy
stone
632 Missed abortion
Early fetal death before

completion of 22
weeks' gestation with
retention of dead fetus
ICD-10
Other abnormal
products of conception
O02.0 Blighted ovum and
nonhydatidiform mole
Mole: carneous, fleshy,
intrauterine NOS,
Pathological ovum
O02.1 Missed abortion
Incl.:Early fetal death
with retention of dead
fetus
O02.8 Other specified
abnormal products of
conception
29
4:00 - 5:00 pm Feb 1, 2013
663 Umbilical cord

complications.
P02 Umbilical cord

complications
Requires fifth digit; valid digits are in [brackets] under

each code. See beginning of section 660-669 for
definitions.
663.0 Prolapse of cord [0,1,3]

663.1 Cord around neck, with
compression[0,1,3]
663.2 Other and unspecified cord
entanglement, with compression
[0,1,3]
663.3 Other and unspecified cord
entanglement, without mention of
compression [0,1,3]
663.4 Short cord [0,1,3]
663.5 Vasa previa [0,1,3]
663.6 Vascular lesions of cord
[0,1,3]
663.8 Other umbilical cord
complications [0,1,3]
663.9 Unspecified umbilical cord
complication [0,1,3]
P02.4 Fetus and newborn affected

by prolapsed cord
by other compression of umbilical
cord
by other and unspecified
conditions of umbilical cord
Polyp of female genital tract

ICD-9
621.0 Polyp of corpus uteri

622.7 Mucous polyp of cervix
219.0 Other benign neoplasm
of uterus : cervix uteri
(adenomatous polyp of
cervix)
623.7 Polyp of Vagina
624.6 Polyp of labia and vulva
221 Benign neoplasm of other
female genital organs
(including adenomatous polyp
and benign teratoma)
ICD-10
N84.0 Polyp of corpus uteri

N84.1 Polyp of cervix uteri
N84.2 Polyp of vagina
N84.3 Polyp of vulva
N84.8 Polyp of other parts of
female genital tract
N84.9 Polyp of female genital
tract, unspecified
30
4:00 - 5:00 pm Feb 1, 2013
My biggest fear about ICD-10 is:
er
0%
O
th
l..
ne
ed
to
r.
..
to
0%
.
0%
W
ill
ea
se
d
e
In
cr
wi
ll
ha
v
I
0%
...
0%
to
...
5.
ni
4.
n
ee
d
3.
d
e
2.
I will have to buy

new software.
Increased denials.
Will need to revise
billing sheets.
Will need to learn
new codes.
Other
W
ill
1.
HELP
Sources:
Essential guide to Coding in OB/GYN

OB/GYN Coding Manual
FAQ for OB/GYN
CPT-4 and ICD-9 books/online
Coding courses
31
4:00 - 5:00 pm Feb 1, 2013
Objectives
Review
Coding Documentation
Guidelines
ICD-9 and ICD-10
32

Hathaway 1

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Hathaway 1

Hochgeladen von

Copyright:

Verfügbare Formate

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

Coding Made Easy

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

How does your office determine

$tandardize the de$cription of

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

does not allow you to code for

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

Evaluation & Management

What is the definition of

Anyplace that isnt

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

Medical Decision Making

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

Chief Complaint (reason for the visitdoesnt have to be a

2 types brief or extended.

Brief has 1-3 elements

Mrs. A c/o vaginal bleeding, heavy (could use pad count),

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

12 areas: Constitutional, Eyes, ENT, CV,

PFSH (Past, Family, Social History)

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

A c/o amenorrhea for 6

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

Guidelines: Not good for basic

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

3 vitals (BP, Pulse, Resp, Temp, Ht, Wt)

Exam of Abdomen (masses, tenderness)

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

Palpation of lymph nodes: neck, axillae, &/or groin.

Problem Focused: 1-5 elements

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

All Consitutional: 3 vitals, general appearance.

Palpation of lymph nodes: neck, axillae, &/or groin.

Inspection and Palpation (rash, lesion, ulcer)

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD

4:00 - 5:00 pm Feb 1, 2013

All of the following body parts get

2013 MSACOG Snow Meeting

Jon Hathaway, MD PhD