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Explore This IssueJune 2010
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- D: This is just one of the three parts for the medical decision-making segment of an evaluation and management (E/M) visit. Medical decision making is made up of three parts: number of diagnoses or treatment options, amount and/or complexity of data to be reviewed, and the risk of complications and/or morbidity or mortality. (See “Breaking Down Medical Decision Making” on page 16 for more information.)
- True: A chief complaint must be in each patient’s medical record for every office visit. Not having one could constitute the visit as not medically necessary.
- E: An extended HPI consists of four of the eight HPI elements (i.e., location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms), or the status of at least three chronic or inactive conditions.
- D: To reach a comprehensive history level, all four elements of history—CC, HPI, ROS, and the PFSH—must be obtained. Note: For a new patient, consultation, or initial hospital visit, all three of the PFSHs must be documented (versus an established or emergency-room patient when only two of the three PFSHs are needed) to reach a comprehensive level of history. An extended HPI and a complete ROS must also be obtained.
- D: The risk of complications and/or morbidity or mortality is broken into three categories: presenting problems, diagnostic procedures ordered, and management options selected. A diagnosis of severe RA is categorized under presenting problems at a high level of risk.