TheMcGraw-HillCompanies-INTRODUCTIONTOCPT：美国麦格劳-希尔公司介绍CPT

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1、INTRODUCTIONTOCPTPARTTHREEChapter7McGraw-Hill/IrwinCopyright©2009byTheMcGraw-HillCompanies,Inc.Allrightsreserved.CPT:EvaluationandManagementCodesLEARNINGOUTCOMESAfterstudyingthischapter,youshouldbeableto:DescribetheorganizationoftheCPTEvaluationandManagement(E/M)section

2、ofCPTDiscusstheuseofthesectionguidelinesasaresourceforE/Mcoding.ListfivequestionsthatareusedtoselectappropriateE/Mcoderangesandassigncorrectcodes.StatethedifferencebetweennewandestablishedpatientsinCPTterms.Discussthethreekeycomponentsthatdeterminethelevelofservice,list

3、ingthefourlevelsofeach.DescribetheprocessusedtodeterminethelevelofserviceforE/Mcoding,includingthepartplayedbythecontributingcomponents.Compareandcontrastconsultationsandnewpatient(referral)E/Mservices.Discussthefactorsthatareimportantinassigningcriticalcarecodes.Define

4、observationandstandbyservices.AssignCPTE/Mcodes,correctlyapplyingtherulesandexceptionsforeachcategoryofservice.KEYTERMScategoryChiefcomplaint(CC)ConsultationConsultingphysicianContributorycomponentsCoordinationofcareCounselingCriticalcareDirectcareE/McomponentsEstablish

5、edpatientEvaluationandmanagement(E/M)codesExaminationFace-to-facetimeFamilyhistoryHistoryHistoryofpresentillnessKeycomponentsLevelofservice(LOS)Medicaldecisionmaking(MDM)Newpatient1995DocumentationGuidelines1996DocumentationGuidelinesObservationPasthistoryPlaceofservice

6、(POS)PresentingproblemPreventivemedicineProblem-orientedProfessionalservicesReferralReferringphysicianReviewofsystemsRoll-upruleSocialhistoryStandbyTimeUnit/floor/timeCODEORGANIZATIONE/McodesbreakdownintocategoriesandsubcategoriesCategories–examplesare:Officeoroutpatien

7、tservicesHospitalobservationservicesHospitalInpatientservicesSubcategories–examplesare:NewpatientEstablishedpatientDischargeservicesSeetable7.1forthecompletelistingSELECTIONPROCESSAstandardsetofquestionsusedfordeterminingthecorrectE/Mcodecategory:Whoisthepatient?Whatist

8、heplaceofservice?Whatisthepatient’sstatus?Whattypeofserviceisbeingprovided?Whatlevelofserviceisbeingprovided?W