Preventive medicine visits require a comprehensive history, comprehensive physical and then counseling, risk factor reduction that are appropriate given the woman’s age.
So bear in mind that if you have a standardized form or electronic medical record, the ability to document a review of at least ten systems will be required in order to meet the requirements needed to bill those preventive medicine visits or those higher level evaluation management visits.
A past history would include illnesses, operations or hospitalizations, medications. Family history would include any chronic illnesses suffered by the family inherited diseases, syndromes, genetic things that might affect the woman’s health care.
Social history would then include perhaps her employment status, educational level, any past history of substances including alcohol, cigarettes or drug use and perhaps a sexual or contraceptive history.
Types Of History In Evaluation Of Management Coding
Let us move on to the types of history that are found in evaluation of management coding. And four types of history are noted, problem focused history, expanded problem focused history, a detailed and comprehensive history.
If you were to bill a detailed history, you would need an extended history of the present illness. Two to nine systems would have to be included in your documentation review of systems. You would need a pertinent past family social history. So this gives you an idea how to arrive at the conclusion of what type of history has been performed and documented when determining the level of evaluation and management code that you would be billing.
The four levels of examination that are listed in CPT coding are the same levels of history, problem focused, expanded problem, focused, detailed and comprehensive.
When we are determining the amount of medical decision making that make up the third leg of the formula of an evaluation and management visit, we need to consider three things. And that would be the number of diagnosis or number of management options that we're considering, that amount and complexity of data to be obtained and the risk to the patient whether in arriving at the diagnosis, the diagnosis itself or the treatment for the problem.
So when we are looking at medical decision, we have to consider – how much data, do we have lab works, do we have ultrasounds, do we have to get an old chart, do we have to talk to someone other than the patient to find out what's going on with her perhaps like care provider in the case of an elderly woman, you may have to talk to someone at the nursing home or her daughter.
How many differential diagnoses there are? For instance, a woman walks in with right lower quadrant pain. And she might be late for a period and she had some spotting. There are many differential diagnoses to be considered there whereas if someone walks in with the history of going out the dentist and getting ampicillin and she's now developed vaginal itching, the list of a differential diagnosis becomes much shorter.
Determining the level of medical decision making is probably the area where many providers discount what they know and what they've been trained to do because arriving at differential diagnosis and going to a management plan field, straightforward.
And a lot of people try to pick an evaluation management code based on the amount of time they spent with the patient saying, “This was a pretty brief visit so therefore I should choose a lower level code.” When in fact, many people discount the medical decision making because again, you do get paid for the education training experience and knowledge that enables you to arrive at sound differential diagnosis and management in a time efficient way.