E/M Template

Evaluation and Management (E/M) Template

PT TYPE: OFFICE/NEW_____ OFFICE/EST _______

Hosp Obs____ Hosp Obs w/ Adm & DC ______ ER ________ CONSULT OFC/OP _________Consult Initial IP______

Consult FU IP______ Consult Confirm_______

Nursing facility Initial Comprehensive Assessment_____

Nursing facility Subsequent______

CC_____________

HISTORY

HISTORY OF PRESENT ILLNESS:

____Location diffuse/localized, unilateral/bilateral, fixed/migratory

____Duration How long? 20 min, onset 3 yrs ago, since last Friday, for approx 2 months, since yesterday

____Quality sharp, dull, burning, gnawing, fullness, aching, throbbing, stabbing, radiating, color of sputum, non-productive, asymptomatic etc. Laceration jagged/straight. Sore throat scratchy

____Context What was going on at time symptoms occurred, exercise, big meals, dairy products, spicy foods, etc. What were they doing when it occurred, MVA, running down steps, sitting in chair, playing sports.

____Severity Rank of pain on pain scale 0-10, severe, slightly, worst I’ve ever had, mild, moderate, 0 pain, increase, decrease, progressive, well, major, poor, significant, complicated (must be ranked; can’t just say “pain in my leg”

____Modifying Factors What makes better or worse, any meds helping, rest or eating, affected by spicy foods, ice pack or quiet room for MHA, coughing irritates the pain, OTC or prescribed meds have been attempted, etc What were the results?

____Timing Onset, night, day, continuous, occasional, episodic, AM, PM, constant, recurrent, seldom, frequently, off and on, morning, evening, intermittent, transient.

____Signs/Symps Associated with…, Negative Responses will count

Document of at least 3 chronic/inactive conditions_____

REVIEW OF SYSTEMS:

Negative, Normal, WNL can count in any/all systems
_____Constitutional – Activity, appearance, appetite, exercise, fatigue, fevers, mood, sweats, weakness, wt change, chills

_____Eyes - Blurred vision, drainage, dryness, flashing, pain, photophobia, redness, tearing, vision change

_____ENT & Mouth - Airway, balance, bleeding, discharge, hearing, pain, ringing, smell, swallowing, taste, voice

_____CV - Chest pain, diaphoresis, dizziness, exertional pain, irregular beats, leg cramps, orthopnea, palpitations, peripheral edema, radiation, SOB

_____Respiratory - Allergies, cough, dyspnea, hemoptysis, pain, SOB, sputum, wheezing

_____GI - Appetite, Change in bowel habits, constipation, diarrhea, heartburn, hemetemesis, indigestion, nausea, pain, rectal bleed, swallowing, thirst, vomiting

_____GU – Burning, discharge, dribbling, frequency, hematuria, incontinence, menopause, nocturia, odor, pain, pregnancies, starting, stopping, urgency, dyuria

_____All/Imm – Allergies to meds, chemo, hay fever, HIV/AIDS, hives, immune suppression, immunizations, sweating

_____MS - Limitation of activity, pain, redness, stiffness, swelling, weakness

_____Skin – bleeding, color change, cyanosis, dryness, growths, jaundice, rash

_____Neuro – blackout, HA, memory loss, numbness, seizure, syncope, tingling, tremors

_____Psych – Anxiety, delusion, depression, hallucination, insomnia, nervous, panic, personality, phobia, suicidal

_____Endocr – Change hair pattern, heat/cold intolerance, polydiipsia, Polyphagia, polyuria, sweating

_____Hem/Lym – bleeding, bruising, gland swelling, menses, nodes

_____Documentation of adequate ROS & all others negative


PFSH :

_____Past Medical History

Surgeries

Any item labeled as PMH may only be used for that. This is true for even chronic 

problems. Don’t try to count them for HPI or ROS elements

Diagnostic tests, even when they appear in the HPI area, can only be used as PMH.

Don’t try to count them as something else

_____Family History

Family History of Neoplasms

Family History of Congenital / Hereditary conditions

_____Social History

Smoking, Alcohol, Marital status

____Unable to do comprehensive history due to patient condition

PHYSICAL EXAM

CONSTITUTIONAL (2) 

____BP, Pulse, Respiration, Temp, Ht, Wt Measurement of any 3 of the above VS. (May be measured/recorded by staff person)

____GENERAL APPEARANCE – Development, Nutrition, Body habitus, Deformities, Grooming

EYES (3)

____ Conjunctivae, Lids

____ Pupils and Irises PERRLA

____ SCOPE EXAM, Optic discs, C/D ratio (Cup to Disk Ratio), Size,Appearance
Posterior segments,Vessel changes, Exudates, hemorrhages

EARS, NOSE, MOUTH, THROAT (6)

____External auditory canals, TM’s

____EARS & NOSE – Appearance, Scars, Lesions, Masses

____Hearing, Whispered voice, Finger rub, Tuning Fork

____NOSE - Mucosa, Septum, Turbinates

____MOUTH – Lips, Teeth, Gums

____THROAT/OROPHARYNX – Oral mucosa, Salivary glands, Hard and soft palates, Tongue, Tonsils, Posterior pharynx

NECK (2) 

____NECK – Masses, Appearance, Symmetry, Tracheal position, Crepitus

____THYROID – Enlargement, Tenderness, Mass

RESPIRATORY (4) 

____Effort, Retractions, Muscles, Movement

____Percussion, Dullness, Flatness, Hyper resonance

____Palpation, Fremitus

____Auscultation, Breath sounds, Rubs

CARDIOVASCULAR (7) 

____Palpation, Location, Size, Thrills

____Auscultation, Abnormal sounds, Murmurs

          ARTERIES –
____Carotid, Pulse, Bruits

____Abdominal Aorta,Size, Bruits

____Femoral, Pulse, Bruits

____Pedal Pulse

____Extremities, Edema, Varicosities

CHEST/BREASTS (2)

____Breasts, Symmetry, Nipple discharge

____Breasts and axillae, Mass, Lump, Tenderness

GI/ABDOMEN (5) 

____Abdomen, Mass, Tenderness

____Liver, Spleen

____Hernia

____Anus, Perineum, Rectum, Sphincter tone, Hemorrhoids, Rectal mass

____Occult blood


GU, FEMALE (6)

____External genitalia, Appearance, Hair distribution, Lesions,

____Vagina, Appearance, Estrogen effect, Discharge, Lesions, Pelvic support, Cystocele, Rectocele

____Urethra, Mass, Tenderness, Scarring

____Bladder, Fullness, Mass, Tenderness

____Cervix, Appearance, Lesions, Discharge

____Uterus, Contour, Position, Mobility, Tenderness, Consistency, Descent or Support

____Adnexa/Parametria, Mass, Tenderness, Organomegaly, Nodules

GU, MALE (3)

____Scrotum, Hydrocele, Spermatocele, Tenderness of cord, Testicular mass

____Penis, phallus 

____DRE of prostate for Size, Symmetry, Nodules, Tenderness 

LYMPHATIC (4) 

 ____Nodes

 ____Neck

 ____Axillae 

____Groin

____Other

MS (26) 

____Gait, Station, Romberg, Ambulatory?? 

____Nails/Digits, Clubbing, Cyanosis, Inflammation, Petechiae, Ischemia, Infection, Nodes

HEAD AND NECK

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion, EOMI

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

SPINE, RIBS, AND PELVIS

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements 

EXTREMITIES, RUE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

EXTREMITIES, LUE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

RLE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

LLE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

SKIN (2) 

____Inspection, Rash, Lesion, Ulcer

____Palpation, Induration, Nodule, Tightening

NEURO (3) 

____Cranial deficits

____DTR, Babinski

____Sensation, Touch, Pin, Vibration, Proprioception

PSYCH (4) 

____Judgement, Insight

____AO x 3

____Memory, recent and remote

____Mood and affect, Depression, Anxiety, Agitation


MEDICAL DECISION MAKING:

DX: TYPE OF PROBLEM:

_____Self-limited or minor

_____Established same/improving ____ Established, worsening

_____New, no additional workup ____New, with additional workup

_____Are any of the above illnesses a severe exacerbation, progression or side effect of treatment?

MANAGEMENT OPTIONS:

_____OTC Meds ____Phys/Occ Therapy

_____Prescrip/IM meds ____Closed Fx/dislocation w/o

_____IV meds manipulation

_____IV meds w/ additives ____Minor surg w/o risk factors

_____High Risk meds ____Minor surg w/ risk factors

_____Telemetry ____Major surg w/o risk factors

_____Respiratory treatments ____Major surg w/ risk factors

_____Nuclear Medicine ____Major emergency surger

____Decision not to resuscitate

----------------------------

_____Decision to obtain old medical records and/or obtain Hx from someone other than patient

_____Review and summ of old records and/or obtain Hx from someone other than patient

_____Discussion of case with another health care provider

Time spent in minutes w/ patient or family_____________


LABS:

_____CBC/UA ____Cardiac enzymes

_____Flu/Strep/Monospot ____ABG

_____PG test _____PT/PTT

_____Amylase _____T&C

_____BUN/Creat _____Superficial Bx

_____Electrolytes _____Deep/incisional Bx

_____ETOH/Drug screen ____Other labs 0-9

_____Chem profile 

----------------------

_____Independent visualization of test

_____Discussion w/ performing physician

X-RAY/RADIOLOGY:

_____Chest ____GI/Gallbladder series

_____Extremities ____IVP

_____Abdomen ____CAT scan

_____Hip/Pelvis ____MRI

_____C-spine ____Vascular studies w/o risk

_____Diagnostic US ____Vascular studies w/ risk

_____Discography ____Other X-ray 0-9

_____T/L spine

-----------------------

_____Independent visualization of test

_____Discussion w/ performing physician

OTHER DIAGNOSTIC TESTS:

_____EKG ____Nuclear scan

_____Holter ____Lumbar puncture

_____Treadmill/stress ____Thoracentesis

_____EEG/EMG ____Culdocentesis

_____Vectorcardiogram ____Endoscope w/o risk

_____Doppler flow ____Endoscope w/ risk

_____Pulmonary

------------------------------

_____Independent visualization of test

_____Discussion w/ performing physician

Coding Certifications (CREDENTIALS)

Types of Medical Coding Certifications (CREDENTIALS)

AHIMA: (American Health Information and Management Association)

RHIA                   -           Registered Health Information Administrator

RHIT                   -           Registered Health Information Technician

CCA                     -           Certified Coding Associate

CCS-P                  -           Certified Coding Specialist – Physician Based

CCS                      -           Certified Coding Specialist – Hospital (Facility) Based

CHDA                  -           Certified Health Data Analyst

CHPS                   -           Certified in Healthcare Privacy and Security

CDIP                    -           Certified Documentation Improvement Practitioner

Website: www.ahima.org

AAPC: (American Academy of Professional Coders)

CPC          -           Certified Professional Coder – Physician Based

CPC-H     -           Certified Professional Coder – Hospital (Facility) Based

CPC-P      -           Certified Professional Coder – Payer

CIRCC    -           Certified Interventional Radiology Cardiovascular Coder

CPMA      -           Certified Professional Medical Auditor

CPCO      -           Certified Professional Compliance Officer

CPPM      -           Certified Physician Practice Manager

Specialty Exams offered by AAPC

Ambulatory Surgical Center – CASCC

Anesthesia and Pain Management – CANPC

Cardiology – CCC

Cardiovascular and Thoracic Surgery – CCVTC

Chiropractic – CCPC

Dermatology – CPCD

Emergency Department - CEDC

Evaluation and Management – CEMC

Family Practice – CFPC

Gastroenterology – CGIC

General Surgery – CGSC

Hematology and Oncology – CHONC

Internal Medicine – CIMC

Obstetrics Gynecology – COBGC

Orthopaedic Surgery – COSC

Otolaryngology – CENTC

Pediatrics – CPEDC

Plastics and Reconstructive Surgery – CPRC

Rheumatology – CRHC

Surgical Foot & Ankle – CSFAC

Urology – CUC

Website: www.aapc.com

ARHCP: Association of Registered Health Care Professionals

RMC                    -           Registered Medical Coder

RMM                   -           Registered Medical Manager

RMA                    -           Registered Medical Auditor

Website: www.arhcp.com

PMI : Practice Management Institute

CMC                    -           Certified Medical Coder

CMIS                   -           Certified Medical Insurance Specialist

CMOM               -           Certified Medical Office Manager

CMCO                -           Certified Medical Compliance Officer

Website: www.pmimd.com

NAHQ : National Association for Healthcare Quality

CPHQ      -           Certified Professional in Healthcare Quality

Website: www.nahq.org

Sample CPC/CPC-H Questions 2

Sample/Practice/Free CPC/CPC-H Coding Exam Questions

1. Jill is a 29-year-old patient of Dr. Marks. She is seen by Dr. Marks for a cough with wheezing and yellow-colored mucus of three days’ duration, as well as four days of external bleeding hemorrhoids and diarrhea. Dr. Marks gives Jill Amoxicillin for acute viral bronchitis, instructions for care of external hemorrhoids, and a diet plan to assist with the diarrhea. What diagnoses should Dr. Marks use for this encounter?

a. 466.0, 455.5, 787.91

b. 787.91, 466.11, 455.5

c. 466.11, 787.91, 455.2

d. 466.0, 455.8, 787.91

2. What HCPCS Level II code describes Ensure HN therapy with an enteral infusion pump with alarm?

a. B4150, B9002

b. B4152, B9000

c. B4150

d. None of the above

3. Which types of joints are considered synovial?

a. Suture joint, medial joint, and articulation joint

b. Ball-and-socket joint, hinge joint, and saddle joint

c. Pivot joint, talus joint, and cranial joint

d. Ball-and socket joint, nasal joint, and elevation joint

4. A physician applied a cast and also provided all of the subsequent fracture care. The same physician may report the application of the cast separately from the fracture care.

a. True

b. False

5. Immediately prior to inserting a permanent pacemaker and placing an electrode in the ventricle, the same physician surgically created a pocket to hold the pulse generator. How should the physician report the creation of the pocket?

a. Skin pocket is included

b. 33222

c. 33222, 33215-51

d. 33233

6. What modifier should be used for an incomplete colonoscopy when the patient was prepared for a full colonoscopy?

a. 78

b. 52

c. 24

d. None of the above

7. A physician inserts a single temporary transvenous pacing catheter into the right atrium and connects the electrode to an external pulse generator. How should the physician report these services?

a. 33214

b. 33206

c. 33210

d. 33211-52

8. A surgeon performs a diagnostic laparoscopy followed by a laparoscopic

nephrectomy (including partial ureterectomy). How should the physician report these services?

a. 50546

b. 49320, 50546-51

c. 49320

d. 50549

9. It is appropriate to separately report a visceral repair when a closure of an

ureterovisceral fistula is performed during the same surgical session.

a. True

b. False

10. A dermatologist excises a 3.5 cm benign lesion from a patient’s back. After the lesion is successfully removed, the dermatologist performs an intermediate 3.5 cm layered closure. How should you report these services?

a. 11404, 12031

b. 11404, 12032-51

c. 11404

d. 11404, 12032-57

11. How would a physician report a bilateral diagnostic nasal endoscopy followed by endoscopic debridement of the nasal cavity during the same operative session?

a. 31240, 31237

b. 31254

c. 31237-50

d. 31237

12. What is the name of a procedure that involves the passage of an endoscope down through the esophagus?

a. Septoplasty

b. Sinusotomy

c. Laryngoscopy

d. Esophagoscopy

13. A physician excises a lesion from the iris of the right eye. How should the physician report these services?

a. 66761-50

b. 66770-RT

c. 66635-52

d. 66600-RT

14. A patient presents to have corns removed from his foot. The physician performs paring to successfully remove four lesions. How should the physician report these services?

a. 11056

b. 11056, 12000

c. 11056 x 4

d. 11704

15. The subsection microbiology in the Pathology and Laboratory section of the CPT Manual includes codes for bacteriology, mycology, parasitology, and  virology.

a. True

b. False

16. A 13-year-old patient suffering from end-stage renal disease received a full month of services, including growth and development assessment, parent counseling, and monitoring of adequate nutrition. These services were completed in an outpatient facility. How would the physician report these services?

a. 90999

b. 97803, 90924

c. 90920

d. 90924

17. A patient is admitted to the hospital for insertion of 15 interstitial radiation ribbons. How would the facility report the radiology services?

a. 77778

b. 99222, 77763

c. 77777-TC

d. 77762 x 15

18. Mrs. Smith was seen by her family physician, Dr. Marks. Mrs. Smith complains she has had a sore throat, breathing problems, and a fever for five days. She is a diabetic patient and has been taking over-the-counter medications that have interfered with her insulin medication. Dr. Marks documented a detailed history, detailed examination, and moderately complex decision-making. Dr. Marks spent 35 minutes with the patient during the examination. How should the physician report this service?

a. 99215

b. 99204

c. 99205

d. 99214

19. Pediatric critical care patient transport codes include vascular access procedures, blood gases, and review of information data stored in computer.

a. True

b. False

20. An anesthesiologist administers anesthesia for a male patient prior to the surgeon performing a total hip replacement. The patient is 75 years old and suffers from mild hypertension. How should you code the anesthesia services?

a. 01214, 99100-59

b. 01214-47

c. 01214-P2, 99100

d. 01214-P3

Answers

1.      A

2.      A

3.      B

4.      B

5.      A

6.      B

7.      C

8.      A

9.      B

10. B

11. C

12. D

13. D

14. A

15. A

16. C

17. A

18. D

19. A

20. C