Emergency department Facility level calculation

For billing of medical records and to code a particular chart patients are identified as two types one is new and other is established patient, depending on encounters with the provider. But in Emergency department a patient will be always a new patient.

New Patient: A person who has not received any professional services from the physician or another physician of the same speciality who belongs to the same group or department within the previous 3 years.

Established Patient: A person who received professional services from the physician or another physician of the same speciality who belongs to the same group or department  within the previous 3 years

Chief Complaint (CC):  A CC is a concise statement that describes the symptom, problem, condition,  diagnosis, or reason for the patient encounter.

History of present illness:

History of the present illness					Review of systems
Elements					Constitutional Symptoms				for example, fever, weight loss
Location		Left leg			Eyes				Normal
Quality		Aching, burning, radiating pain			Ears, nose, mouth, throat				Normal
Severity		10 on a scale of 1 to 10			Cardiovascular				Normal
Duration		started 3 days ago			Respiratory
Timing		constant or comes and goes			Gastrointestinal
Context		lifted large object at work			Genitourinary
Modifying Factors		Better when heat is applied			Musculoskeletal
Assoc signs and symptoms		Numbness in toes			Integumentary (skin and/or breast)				Laceration to hand
					Neurological
					Psychiatric
					Endocrine
					Hematologic/lymphatic
					Allergic/immunologic
Total HPI ·        Brief=1-3 ·        Extended=4+or status of 3 or more chronic  conditions					Total ROS: Pertinent= 1 Extended=2-9 Complete=10+
Past medical history				Family history					Social History
Past illness				Family illness					Smoking
Past surgeries				Hereditary disease					Alcohol drug use
Allergies				Health status of family members					Living arrangements
Current meds									Employment occupation
Past hospitalization									Marital status
Past injuries									Hobbies/Activities
Total PFSH			Established patient, Emergency department Visit ·        Pertinent PFSH= 1 element from any history ·        Complete PFSH=1 element from any 2 history areas					New patient , initial encounter   ·        Pertinent PFSH= 1 Element from  1 or 2 history areas ·        Complete PFSH=1 element from each of the 3 history

 

HPI Calculation Table:

Physical examination:

Count the examination as either a body area or organ system but do not club it based on 1995 and 1997 guidelines.

1.Body area	2. Organ system
Head	Constitutional Symptoms
Neck	Eyes
Chest	Ears, nose, mouth, throat
Abdomen	Cardiovascular
Genitalia	Respiratory
Back	Gastrointestinal
Each Extrimity	Genitourinary
	Musculoskeletal
	Integumentary (skin and/or breast)
	Neurological
	Psychiatric
	Endocrine
	Hematologic/lymphatic
	Allergic/immunologic

 

Physical Examination Calculation Table:

 

Medical decision making:

Based on the level of Risk medical decision making is calculated.  Below is the table for reference.

 

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