This presentation discusses the key components (history, physical exam, and medical decision making), used in CPT’s evaluation and management (E/M) medical codes.
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The video starts with a definition of E/M codes and then discusses each key component, how to determine the level of each (problem-focused, expanded problem-focused, detailed or comprehensive for history and exam; straightforward, low complexity, moderate complexity, or high complexity for medical decision making [MDM]). These levels are used to select the correct E/M code in most cases, but sometimes time can be used to select a code.
The history component includes chief complaint, history of present illness, review of systems, and past/family and social history. The examination includes counting number of body areas or organ systems examined. Medical decision making includes number/complexity of problems addressed; amount and/or complexity of data reviewed and analyzed; and risk of complications/morbidity/mortality of patient management. Each of these components are discussed.
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Contents of this video:
0:00 - Introduction
5:08 - History key component
18:36 - Exam key component
24:21 - MDM key component
31:27 - Selecting the code
41:47 - Typical Time
46:07 - Notes to make in your Book
