determine level of 99 code 1. em rules in cpt manual 9 pages, starting pg 4, cpt 2013 em rules by...

Determine Level of 99 Determine Level of 99 Code Code

11


EM Rules in CPT ManualEM Rules in CPT Manual9 pages, starting pg 4, CPT 20139 pages, starting pg 4, CPT 2013

EM Rules by MedicareEM Rules by Medicare15 pages of 1995 Documentation Guidelines 15 pages of 1995 Documentation Guidelines

(DG) for EM Services (DG) for EM Services

53 pages of 1997 DG for EM Services 53 pages of 1997 DG for EM Services (skip pg.14-24, 27-45)(skip pg.14-24, 27-45)

22


November 2005- November 2005-

Medicare carriers are to use 1995 Medicare carriers are to use 1995 and 1997 DGs to review EM and 1997 DGs to review EM Services Services

(whichever is more advantageous to (whichever is more advantageous to the physician) the physician) until further noticeuntil further notice

33


Non-Medicare plans may or may not Non-Medicare plans may or may not use DGsuse DGs

Advantages to use them anyway – Advantages to use them anyway –

a) Defendable during audita) Defendable during audit

b) Improves on ambiguity of CPTb) Improves on ambiguity of CPT

44


Website for DG 95 & 97Website for DG 95 & 97

http://www.cms.hhs.gov/http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.aspMLNEdwebGuide/25_EMDOC.asp

55

Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation

Only way to guard against audit Only way to guard against audit losseslosses

66


3 Main Elements of 99 Codes3 Main Elements of 99 Codes

1. History1. History

2. Examination2. Examination

3. Medical Decision Making (MDM)3. Medical Decision Making (MDM)

77


Grade each Main Element Grade each Main Element

Use chart to choose final 99 CodeUse chart to choose final 99 Code

Slow start - Quicker as weeks passSlow start - Quicker as weeks pass

88






99


HistoryHistory

Inadequate history is single most Inadequate history is single most common reason for downgrading common reason for downgrading during auditduring audit

Record history the same way, the Record history the same way, the same detail, for same detail, for allall patients patients

1010


History ElementsHistory Elements

a) Chief Complainta) Chief Complaint

b) History of Present Illnessb) History of Present Illness

c) Review of Systemsc) Review of Systems

d) Past, Family, Social Historyd) Past, Family, Social History

1111







1212


Chief Complaint (CC)Chief Complaint (CC)

Concise statement describing symptom, Concise statement describing symptom, problem, condition, diagnosis, problem, condition, diagnosis, physician recommended returnphysician recommended return, or , or other factor or reason for encounterother factor or reason for encounter

Usually stated in patient's wordsUsually stated in patient's words

1313


Chief ComplaintChief Complaint

Staff may take CCStaff may take CC

If staff takes CC, physician must If staff takes CC, physician must validate CC in documentationvalidate CC in documentation

1414


Chief Complaint Chief Complaint

Required for every level of 99 codeRequired for every level of 99 code

No CC means visit is not medically No CC means visit is not medically necessary, and not medically necessary, and not medically billablebillable

1515


Chief ComplaintChief Complaint

Record as many CC as patient mentionsRecord as many CC as patient mentions

Record as many as you are following at Record as many as you are following at that visitthat visit

Numbering 1, 2, 3, etc.Numbering 1, 2, 3, etc.

1616


Chief Complaint Chief Complaint

Related to complexity of Medical Decision Related to complexity of Medical Decision MakingMaking

MDM is "number of possible diagnoses"MDM is "number of possible diagnoses"

More complaints create more diagnosesMore complaints create more diagnoses

1717






d) Past, Family, Social History.d) Past, Family, Social History.

1818


History of Present Illness (HPI)History of Present Illness (HPI)

Chronological description of development of Chronological description of development of patient's present illness from first sign patient's present illness from first sign and/or symptom, and/or symptom,

or from previous encounter to presentor from previous encounter to present

Only physician can take HPIOnly physician can take HPI

..

1919


HPI ElementsHPI Elements (record 4 of 9)(record 4 of 9)

Location Location

QualityQuality

SeveritySeverity

DurationDuration

TimingTiming

2020


HPI ElementsHPI Elements (record 4 of 9)(record 4 of 9)

ContextContext

ModifiersModifiers

Assoc signsAssoc signs

OtherOther

2121


HPIHPI

Always record Always record FOURFOUR

Less than 4 means highest EM Level is:Less than 4 means highest EM Level is:

Level 2 New PatientLevel 2 New Patient

Level 3 Est. PatientLevel 3 Est. Patient

2222


HPIHPI

4 or more means no restriction on 4 or more means no restriction on choice of EM levelchoice of EM level

HPI examples available – email meHPI examples available – email me

2323







2424


Review of Systems (ROS)Review of Systems (ROS)

Inventory of body systems obtained Inventory of body systems obtained through questions to identify signs through questions to identify signs or symptomsor symptoms

2525



Patient or staff can fill out ROSPatient or staff can fill out ROS

Physician must review ROS and make Physician must review ROS and make notation in chartnotation in chart

2626



Does Does notnot need to be re-recorded if need to be re-recorded if there is evidence physician there is evidence physician reviewed & updated prior ROSreviewed & updated prior ROS

Once done, always doneOnce done, always done

2727



Review & update may be documented by:Review & update may be documented by:

• • describing new ROS information, or describing new ROS information, or

noting there is no change in noting there is no change in information; andinformation; and

• • noting date and location of earlier ROSnoting date and location of earlier ROS

2828



A A completecomplete ROS inquires about the ROS inquires about the system(s) directly related to the system(s) directly related to the problem(s) identified in the HPI plus problem(s) identified in the HPI plus all additional body systems.all additional body systems.

ROS must be reviewed by pt & doc ROS must be reviewed by pt & doc validate validate eacheach visit visit

2929



A note indicating all systems are A note indicating all systems are negative is permissiblenegative is permissible

3030


Review of Systems (ROS) ElementsReview of Systems (ROS) Elements (record 10 of 14)(record 10 of 14)

ConstitutionalConstitutional

EyesEyes

Ears nose mouth throatEars nose mouth throat

CardiovascularCardiovascular

RespiratoryRespiratory

GastrointestinalGastrointestinal3131


Review of Systems (ROS) ElementsReview of Systems (ROS) Elements (record 10 (record 10 of 14)of 14)

GenitourinaryGenitourinary

MusculoskeletalMusculoskeletal

IntegumentaryIntegumentary

NeurologicalNeurological

PsychiatricPsychiatric

EndocrineEndocrine

3232


Review of Systems (ROS) ElementsReview of Systems (ROS) Elements (record 10 of 14)(record 10 of 14)

Hematologic/LymphaticHematologic/Lymphatic

Allergic/ImmunologicAllergic/Immunologic

3333



Always record Always record TENTEN

2 – 9 means highest EM is:2 – 9 means highest EM is:


Level 4 Est. PatientLevel 4 Est. Patient

3434







3535


Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)

Patient or staff can fill out PFSHPatient or staff can fill out PFSH

Physician must review PFSH and make Physician must review PFSH and make notation in chartnotation in chart

3636



NoNo need to re-record if evidence that need to re-record if evidence that physician reviewed & updated prior physician reviewed & updated prior PFSHPFSH

Once done, always doneOnce done, always done

3737



Review & update may be documented by:Review & update may be documented by:

• • describing new PFSH information, or describing new PFSH information, or

noting there is no change in information; noting there is no change in information; andand

• • noting date and location of earlier PFSHnoting date and location of earlier PFSH

3838



Past HistoryPast History elements elements (record 1 of 7)(record 1 of 7)

Prior major illness & injuryPrior major illness & injury

Prior operationPrior operation

Prior hospitalizationPrior hospitalization

Current medsCurrent meds

3939



Personal HistoryPersonal History elements elements (record 1 of 7)(record 1 of 7)

AllergiesAllergies

Immunization statusImmunization status

Dietary statusDietary status

4040



Social HistorySocial History elements elements (record 1 of 7)(record 1 of 7)

Marital status/Living arrangementMarital status/Living arrangement

Current employmentCurrent employment

Occupational historyOccupational history

Use of drugs, alcohol, tobaccoUse of drugs, alcohol, tobacco

4141



Social HistorySocial History elements elements (record 1 of 7)(record 1 of 7)

Level educationLevel education

Sexual historySexual history

Other social factorsOther social factors

4242



Family HistoryFamily History elements elements (record 1 of 3)(record 1 of 3)

Medical eventsMedical events

DiseasesDiseases

Hereditary conditionsHereditary conditions

4343



Always record Always record ONE FROM EACH CATEGORYONE FROM EACH CATEGORY

Recording 1 means highest EM is:Recording 1 means highest EM is:


Level 4 Est Patient Level 4 Est Patient

4444



1. History1. History (to review)(to review)

EveryEvery patient: document history as if patient: document history as if supporting highest level EMsupporting highest level EM

~Good medicine~Good medicine

~Reveals issues needing management~Reveals issues needing management

4545




~Minimizes History as factor in ~Minimizes History as factor in grading final EMgrading final EM

4646






4747


ExaminationExamination

What level examination is justified?What level examination is justified?

Extent of examination is based on Extent of examination is based on

-Clinical judgment-Clinical judgment

-Patient history-Patient history

-Nature of presenting problems-Nature of presenting problems

4848


Examination ElementsExamination Elements (of 14, record all that apply)(of 14, record all that apply)

Visual Acuity Visual Acuity

Confrontation VF Confrontation VF

Ocular motility test Ocular motility test

Conjunctiva Conjunctiva

Ocular adnexae Ocular adnexae

Pupils & Irises Pupils & Irises

4949


Examination ElementsExamination Elements (of 14, record all that apply)(of 14, record all that apply)

Corneas Corneas

Anterior Chamber Anterior Chamber

Lenses Lenses

IOP IOP

Optic Discs Optic Discs

Posterior Segments Posterior Segments

5050


Examination ElementsExamination Elements (of 14, record all (of 14, record all that apply)that apply)

Orientation Orientation

Mood and affectMood and affect

5151

Determine Level of 99 Determine Level of 99 From Chart Documentation From Chart Documentation

Examination ElementsExamination Elements

Visual Acuity Visual Acuity

Not refractionNot refraction

5252

Determine Level of 99 Determine Level of 99 From Chart Documentation From Chart Documentation


Confrontation VF Confrontation VF

Gross visual field testingGross visual field testing

5353



Ocular motility test Ocular motility test

Primary gaze alignmentPrimary gaze alignment

5454



Conjunctiva Conjunctiva

Bulbar & Palpebral Bulbar & Palpebral

5555



Ocular adnexae Ocular adnexae Lids Lids (eg, ptosis or lagophthalmos)(eg, ptosis or lagophthalmos)

Lacrimal glandsLacrimal glands

Lacrimal drainageLacrimal drainage

OrbitsOrbits

Preauricular lymph nodesPreauricular lymph nodes

5656



Pupils & Irises Pupils & Irises

ShapeShapeDirect & consensual reaction Direct & consensual reaction (afferent pupil)(afferent pupil)

Size Size (eg, anisocoria)(eg, anisocoria)

Morphology Morphology (shape, form)(shape, form)

5757



CorneasCorneas @ slit lamp @ slit lamp

EpitheliumEpithelium

StromaStroma

EndotheliumEndothelium

Tear filmTear film

5858



Anterior chambersAnterior chambers @ slit lamp @ slit lamp

Depth Depth

CellsCells

FlareFlare

5959



LensesLenses @ slit lamp @ slit lamp

ClarityClarity

Anterior & posterior capsuleAnterior & posterior capsule

CortexCortex

NucleusNucleus

6060



IOP IOP

Except in children & Except in children &

Patients with trauma or infectious diseasePatients with trauma or infectious disease

6161



Optic DiscsOptic Discs Thru dilated pupils, unless contraindicated:Thru dilated pupils, unless contraindicated:

SizeSize

C/D ratioC/D ratioAppearance Appearance (eg, atrophy, cupping, tumor elevation)(eg, atrophy, cupping, tumor elevation)

Nerve fiber layerNerve fiber layer

6262



Posterior SegmentsPosterior Segments Thru dilated pupils, unless Thru dilated pupils, unless contraindicated:contraindicated:

Retina & vessels Retina & vessels eg, exudates & hemorrhageseg, exudates & hemorrhages

6363



OrientationOrientation (mental status)(mental status)

To time, place and personTo time, place and person

Brief assessment Brief assessment

6464



Mood and affectMood and affect (mental status)(mental status)

eg, depression, anxiety, agitationeg, depression, anxiety, agitation

Brief assessmentBrief assessment

6565


Examination, ScoringExamination, Scoring

NewNew Min. Elements Needed Min. Elements Needed

9920199201 11

9920299202 66 ((orientation + mood orientation + mood + 4)+ 4)

9920399203 9 9 ((orientation + mood orientation + mood + 7)+ 7)

9920499204 11stst 12 + 1 mental 12 + 1 mental


6666


Examination ElementsExamination Elements (of 14, record all that (of 14, record all that apply)apply)

1. Visual Acuity 1. Visual Acuity

2. Confrontation VF 2. Confrontation VF

3. Ocular motility test 3. Ocular motility test

4. Conjunctiva 4. Conjunctiva

5. Ocular adnexae 5. Ocular adnexae

6. Pupils & Irises 6. Pupils & Irises 6767



7. Corneas 7. Corneas

8. Anterior Chamber8. Anterior Chamber

9. Lenses 9. Lenses

10. IOP 10. IOP

11. Optic Discs 11. Optic Discs

12. Posterior Segments 12. Posterior Segments 6868



13. Orientation 13. Orientation (mental)(mental)

14. Mood and affect 14. Mood and affect (mental)(mental)

6969



EstEst Min. Elements Needed Min. Elements Needed

9921199211 00

9921299212 11

9921399213 66 ((orientation + mood orientation + mood + 4)+ 4)

9921499214 99 ((orientation + moodorientation + mood + 7) + 7)


7070



Break points: 1, 6, 9, 12Break points: 1, 6, 9, 12

Blank boxes on exam form, for countingBlank boxes on exam form, for counting

7171


Could stop scoring now, for est. patient –Could stop scoring now, for est. patient –

Need only 2 of 3 Main ElementsNeed only 2 of 3 Main Elements

Example: History & ExaminationExample: History & Examination

7272


For Established Patient, most casesFor Established Patient, most cases

Examination Level = level of EMExamination Level = level of EM

7373


For Hx & Exam, counting system used For Hx & Exam, counting system used

Easy to understand & scoreEasy to understand & score

MDM – not so muchMDM – not so much

7474






7575


Medical Decision Making elementsMedical Decision Making elements

a) Diagnosis & Management Optionsa) Diagnosis & Management Options

b) Complexityb) Complexity

c) Riskc) Risk

(2 of 3 needed, new & est)(2 of 3 needed, new & est)

7676





c) Riskc) Risk

7777


Diagnosis & Management OptionsDiagnosis & Management Options

1997 DG1997 DG Number of possible diagnoses or number of Number of possible diagnoses or number of

management options is based on:management options is based on:

Number & types of problems addressed,Number & types of problems addressed,

Complexity of establishing diagnosis, andComplexity of establishing diagnosis, and

Management decisionsManagement decisions

7878



1997 DG1997 DG Diagnosed problem decisions are Diagnosed problem decisions are easiereasier

Un-diagnosed problem decisions are Un-diagnosed problem decisions are harderharder

7979



1997 DG1997 DG Number & type diagnostic tests indicates number of possible diagnosesNumber & type diagnostic tests indicates number of possible diagnoses

Improving or resolving problems are Improving or resolving problems are less complexless complex

Worsening or failing-to-change-as-expected problems are Worsening or failing-to-change-as-expected problems are more complexmore complex

8080



1997 DG1997 DG Need to seek advice from others Need to seek advice from others indicates complexityindicates complexity

8181



Choices for gradingChoices for grading

NoneNone

MinimalMinimal

LimitedLimited

MultipleMultiple

ExtensiveExtensive

8282


Want help to grade ??Want help to grade ??

8383



CPT & DG: No point systemCPT & DG: No point system

but,but,

HGS Administrators HGS Administrators (Medicare)(Medicare) made a point system made a point system

8484


Problem Type Count of Problems

x Points = Problem Points

Self-limited or minor (maximum of

2)

1

Established problem, stable or improving

1

Established problem, worsening or failing to change as expected

2

New problem, with no additional work-up

planned (maximum 1)

3

New problem, with additional work-up

planned

4

8585



TotalTotal Supports Supports

11 99201 & 99211 99201 & 99211

11 99202 & 99212 99202 & 99212

22 99203 & 99213 99203 & 99213

33 99204 & 99214 99204 & 99214

44 99205 & 99215 99205 & 99215

8686



Exam form Exam form ““DiagnosisDiagnosis”” section, add: section, add:

““New – chronic – improved – stable – worseNew – chronic – improved – stable – worse””

8787


Medical Decision Making elements Medical Decision Making elements



c) Riskc) Risk

(2 of 3 needed, new & est)(2 of 3 needed, new & est)

8888


ComplexityComplexity

1997 DG1997 DGAmount and complexity is based on types of diagnostic tests ordered or reviewedAmount and complexity is based on types of diagnostic tests ordered or reviewed

8989



1997 DG1997 DGDecision to obtain and review old medical records Decision to obtain and review old medical records increasesincreases amount & complexity amount & complexity

Decision to obtain history from source other than patient Decision to obtain history from source other than patient increasesincreases amount & complexity amount & complexity

9090



Choices for grading areChoices for grading are

MinimalMinimal

LimitedLimited

MultipleMultiple

ExtensiveExtensive

9191


Want help to grade ??Want help to grade ??

9292



CPT & DG: No point system CPT & DG: No point system

butbut

HSA Administrators & Trailblazer made point systemHSA Administrators & Trailblazer made point system

file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/A-O/Loose Pages/09 Complexity.xlsx

9393



TotalTotal SupportsSupports

0 or 10 or 1 99201 & 9921199201 & 99211

0 or10 or1 99202 & 99212 99202 & 99212

22 99203 & 9921399203 & 99213

33 99204 & 9921499204 & 99214

44 99205 & 9921599205 & 99215

9494





c) Riskc) Risk

(2 of 3 needed, new & est) (2 of 3 needed, new & est)

9595


RiskRisk (broad scope)(broad scope)

1997 DG1997 DGThe risk of The risk of

(a) significant complications(a) significant complications

(b) morbidity, and/or (b) morbidity, and/or

(c) mortality (c) mortality

is based on risks associated with is based on risks associated with

9696


RiskRisk

1997 DG1997 DG (1) presenting problems(1) presenting problems

(2) diagnostic procedures, and (2) diagnostic procedures, and

(3) possible management options(3) possible management options

9797


RiskRisk

1997 DG1997 DGDetermination of risk is complex and Determination of risk is complex and

not readily quantifiablenot readily quantifiable

9898


RiskRisk

1997 DG1997 DGRisk is related to disease process anticipated Risk is related to disease process anticipated betweenbetween present encounter and next one present encounter and next one

Risk is based on risk Risk is based on risk during and immediately following during and immediately following procedures or treatment.procedures or treatment.

9999


RiskRisk

1997 DG1997 DGA table may be used to help determine riskA table may be used to help determine risk

HighestHighest level of risk in any one category determines overall risk level of risk in any one category determines overall risk

100100


RiskRisk

1997 DG table for general medicine1997 DG table for general medicine

AAO created Risk Table for eyes – unofficialAAO created Risk Table for eyes – unofficialfile://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/A-O/Loose Pages/10 Risk Chart AAO.xls

101101


Risk Risk

Rx med or Cataract surgery referral = Rx med or Cataract surgery referral = ModerateModerate risk risk (level 4 new & est)(level 4 new & est)

Cataract surgery referral with risk factors = Cataract surgery referral with risk factors = HighHigh risk risk (level 5 new & est)(level 5 new & est)

102102


Risk Risk

TotalTotal SupportsSupports

MinimalMinimal 11 99201 & 9921199201 & 99211

MinimalMinimal 11 99202 & 9921299202 & 99212

LowLow 22 99203 & 9921399203 & 99213

ModrtModrt 33 99204 & 9921499204 & 99214

HighHigh 44 99205 & 9921599205 & 99215

103103


Grading Overall MDMGrading Overall MDM

104104


Grading Overall MDMGrading Overall MDM

Of 3 elements Of 3 elements (Diag & Mgmt, Complxty, Risk)(Diag & Mgmt, Complxty, Risk)

Use Use ““Diagnosis & Management OptionsDiagnosis & Management Options”” + + ““RiskRisk”” (ignore Complexity)(ignore Complexity)

Lowest level of support between the two = Lowest level of support between the two =

level of MDMlevel of MDM

105105


For New PatientFor New Patient

Lowest between Exam and MDM = Lowest between Exam and MDM =

level of EMlevel of EM

106106


Review of Big PictureReview of Big Picture

a) a) EveryEvery patient, document history as if supporting highest level EM patient, document history as if supporting highest level EM

107107



b) Established Patientb) Established Patient

Examination Level = level of EMExamination Level = level of EM

108108



c) New Patientc) New Patient

Grade 2 MDM elements Grade 2 MDM elements

Lowest level between Exam and MDM = Lowest level between Exam and MDM =

level of EMlevel of EM

109109


RecommendationRecommendation

For paper chartingFor paper charting

Use EM recording form similar to sampleUse EM recording form similar to sample

For Paperless chartingFor Paperless charting

Adjust History section to accept multiple CCAdjust History section to accept multiple CC

Keep Keep ““Diagnosis & Management OptionsDiagnosis & Management Options”” and and ““RiskRisk”” chart handy chart handy

110110

CPT examples of EMCPT examples of EM

Appendix C of CPT manualAppendix C of CPT manual

111111


9920199201

Initial office visit for 10-yo for Initial office visit for 10-yo for determination of visual acuity as determination of visual acuity as part of summer camp physical part of summer camp physical (does not include refraction)(does not include refraction)

Non-medicalNon-medical

112112


9920399203

Initial office visit for 55 yo with Initial office visit for 55 yo with chronic blepharitis. History of chronic blepharitis. History of many medications.many medications.

Simple but not level 2Simple but not level 2

113113


9920399203

Initial office visit for 18 yo with 2-day Initial office visit for 18 yo with 2-day history of acute conjunctivitis. history of acute conjunctivitis. Extensive history of possible Extensive history of possible exposures, prior normal ocular exposures, prior normal ocular history, medication use is obtained.history, medication use is obtained.

Simple but not level 2Simple but not level 2114114


9920599205

Initial office visit for 29 yo with Initial office visit for 29 yo with acute orbital congestion, lid acute orbital congestion, lid retraction, bilateral visual loss retraction, bilateral visual loss from optic neuropathy.from optic neuropathy.

Vision lossVision loss

115115


99205 Initial office visit for 70 yo 99205 Initial office visit for 70 yo diabetic with progressive VF loss, diabetic with progressive VF loss, advanced optic disc cupping, advanced optic disc cupping, neovascularization of retina.neovascularization of retina.

Vision loss, loss of functionVision loss, loss of function

116116


99211 99211

Multiple scenarios:Multiple scenarios:

~ New copy of lost prescription~ New copy of lost prescription

~ Dressing change~ Dressing change

~ Release to return to school~ Release to return to school

~ Return to work certificate~ Return to work certificate

~ Blood pressure check~ Blood pressure check

~ Instruction in use of a medical device~ Instruction in use of a medical device

117117


9921299212

Office evaluation of possible Office evaluation of possible purulent bacterial conjunctivitis purulent bacterial conjunctivitis with 1-to-2 day history of redness with 1-to-2 day history of redness and discharge, 16 yo, established and discharge, 16 yo, established patient.patient.

118118


9921399213

Office visit for 65 yo, established Office visit for 65 yo, established patient, with primary glaucoma for patient, with primary glaucoma for interval determination of IOP and interval determination of IOP and possible adjustment of medication.possible adjustment of medication.

““IOP checkIOP check””

119119


9921499214

Office visit for 68 yo, established Office visit for 68 yo, established patient, sudden onset of multiple patient, sudden onset of multiple flashes and floaters in right eye due flashes and floaters in right eye due to posterior vitreous detachment.to posterior vitreous detachment.

Common occurrence, serious risk but Common occurrence, serious risk but benign outcome.benign outcome.

120120


9921499214

Office visit for adult diabetic Office visit for adult diabetic established patient with past history established patient with past history of recurrent sinusitis who presents of recurrent sinusitis who presents with 1-week history of double vision.with 1-week history of double vision.

Diabetic complicationDiabetic complication

121121

Prolonged ServiceProlonged Service

file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/Repository of My PowerPoints/1 Topic Modules/Prolonged Srvc/Prolgd Srvc Aug 13.pptx

122122

determine level of 99 code 1. em rules in cpt manual 9 pages, starting pg 4, cpt 2013 em rules by...

Documents

chart documentationgrade

chart documentationonly

main element use chart

social history

auditrecord history

code em rules

em services

patients present illness