CPC 1-2-3! Evaluation and Management Coding Made Easy

Evaluation and Management 1-2-3! Documentation Requirement will address the factors and principles of documentation integrity. At the completion of this lesson the learner will be able to:

1. Define medical necessary and the importance to assigning the correct level of service

2. Recognize the principles of documentation and the elements of a complete record

3. Recognize types of service, place of care, and patient status

4. Define a chief complaint (CC)

History of Present Illness

At the completion of this lesson the  learner will be able to:

1.Define History of Present Illness (HPI)

2.Recognize the HPI elements

3.Differentiate between a Brief or Extended History of Present Illness

Review of System

At the completion of this lesson the  learner will be able to

The learner will be able to:

1.Define Review of Systems (ROS) components

2.Identify the inventory of body systems

3.Identify the minimum level requirement for the ROS

Past Family, Social, History

The learner will be able to:

1.Describe the Past Family, Social, History (PFSH) components

2.Define each PFSH component

3.Determine the PFSH levels

Objectives

The learner will be able to:

Choose an overall MDM level based on:

1.The number of diagnoses or management options

2.The amount and/ or complexity of data to be reviewed

3.The risk of complications and morbidity or mortality

Objectives

The learner will be able to:

1. Differentiate between the 1995 & 1997 Documentation Guidelines

2. Level of Care documentation requirements

3. Application of the 1995 and 1997 DG