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:

HPI Calculation, Medical coding, Evaluaton and Management Emergency Department calculation, TutorialsKey,

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:

Physical Examination Calculation, Medical coding, Evaluaton and Management Emergency Department calculation, TutorialsKey,

 

Medical decision making:

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

 

Medical coding, Evaluaton and Management Emergency Department calculation, TutorialsKey,

 

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