New vs. Established Patients: New patients are those who have not received any professional services from the same physician or a physician of the same specialty within the past three years, while established patients have an existing relationship with the provider. This differentiation is vital because it impacts the selection of the appropriate E/M code and affects the documentation and billing process.
Time-Based E/M Codes: In these instances, the healthcare provider's documented time in direct, face-to-face patient contact is the primary driver for code selection. These codes are particularly useful for services where time is a significant factor, such as psychotherapy or counseling sessions.
The documentation must support the level of E/M code selected for a patient encounter. The key components typically include:
- Chief Complaint (CC): A concise description of the patient's reason for the visit.
- History of Present Illness (HPI): A detailed account of the patient's current symptoms, their onset, duration, location, quality, severity, and any associated factors.
- Review of Systems (ROS): A systematic review of the patient's body systems to identify any additional symptoms or issues.
- Past, Family, and Social History (PFSH): A review of the patient's medical history, family history, and social history, which may include factors like smoking, alcohol use, or living conditions.
- A physical examination of the patient's relevant body systems and areas based on the patient's symptoms and medical history.
Medical Decision-Making (MDM):
- Diagnoses and Management Options: A summary of the diagnoses and possible management options considered during the encounter.
- Data Reviewed: Information about any diagnostic tests, studies, or data analyzed during the encounter.
- Risk Assessment: The provider's assessment of the patient's risk, including potential complications, morbidity, and mortality.
These codes are designed to accurately categorize and document the complexity and intensity of these interactions.