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Determine Level of 99 Determine Level of 99 Code Code
11
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Determine Level of 99 Determine Level of 99 Code Code
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
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Determine Level of 99 Determine Level of 99 Code Code
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
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Determine Level of 99 Determine Level of 99 Code Code
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
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Determine Level of 99 Determine Level of 99 Code Code
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
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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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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)
99
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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.
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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 History.d) Past, Family, Social History.
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
..
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
HPI ElementsHPI Elements (record 4 of 9)(record 4 of 9)
Location Location
QualityQuality
SeveritySeverity
DurationDuration
TimingTiming
2020
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
HPI ElementsHPI Elements (record 4 of 9)(record 4 of 9)
ContextContext
ModifiersModifiers
Assoc signsAssoc signs
OtherOther
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS)Review of Systems (ROS)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS)Review of Systems (ROS)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS)Review of Systems (ROS)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS)Review of Systems (ROS)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS)Review of Systems (ROS)
A note indicating all systems are A note indicating all systems are negative is permissiblenegative is permissible
3030
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS) ElementsReview of Systems (ROS) Elements (record 10 (record 10 of 14)of 14)
GenitourinaryGenitourinary
MusculoskeletalMusculoskeletal
IntegumentaryIntegumentary
NeurologicalNeurological
PsychiatricPsychiatric
EndocrineEndocrine
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS) ElementsReview of Systems (ROS) Elements (record 10 of 14)(record 10 of 14)
Hematologic/LymphaticHematologic/Lymphatic
Allergic/ImmunologicAllergic/Immunologic
3333
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Systems (ROS)Review of Systems (ROS)
Always record Always record TENTEN
2 – 9 means highest EM is:2 – 9 means highest EM is:
Level 3 New PatientLevel 3 New Patient
Level 4 Est. PatientLevel 4 Est. Patient
3434
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
Personal HistoryPersonal History elements elements (record 1 of 7)(record 1 of 7)
AllergiesAllergies
Immunization statusImmunization status
Dietary statusDietary status
4040
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
Family HistoryFamily History elements elements (record 1 of 3)(record 1 of 3)
Medical eventsMedical events
DiseasesDiseases
Hereditary conditionsHereditary conditions
4343
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)
Always record Always record ONE FROM EACH CATEGORYONE FROM EACH CATEGORY
Recording 1 means highest EM is:Recording 1 means highest EM is:
Level 3 New PatientLevel 3 New Patient
Level 4 Est Patient Level 4 Est Patient
4444
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
3 Main Elements of 99 Codes3 Main Elements of 99 Codes
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
3 Main Elements of 99 Codes3 Main Elements of 99 Codes
1. History1. History
~Minimizes History as factor in ~Minimizes History as factor in grading final EMgrading final EM
4646
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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)
4747
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements (of 14, record all (of 14, record all that apply)that apply)
Orientation Orientation
Mood and affectMood and affect
5151
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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
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Determine Level of 99 Determine Level of 99 From Chart Documentation From Chart Documentation
Examination ElementsExamination Elements
Confrontation VF Confrontation VF
Gross visual field testingGross visual field testing
5353
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
Ocular motility test Ocular motility test
Primary gaze alignmentPrimary gaze alignment
5454
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
Conjunctiva Conjunctiva
Bulbar & Palpebral Bulbar & Palpebral
5555
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
CorneasCorneas @ slit lamp @ slit lamp
EpitheliumEpithelium
StromaStroma
EndotheliumEndothelium
Tear filmTear film
5858
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
Anterior chambersAnterior chambers @ slit lamp @ slit lamp
Depth Depth
CellsCells
FlareFlare
5959
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
LensesLenses @ slit lamp @ slit lamp
ClarityClarity
Anterior & posterior capsuleAnterior & posterior capsule
CortexCortex
NucleusNucleus
6060
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
IOP IOP
Except in children & Except in children &
Patients with trauma or infectious diseasePatients with trauma or infectious disease
6161
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
Posterior SegmentsPosterior Segments Thru dilated pupils, unless Thru dilated pupils, unless contraindicated:contraindicated:
Retina & vessels Retina & vessels eg, exudates & hemorrhageseg, exudates & hemorrhages
6363
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
OrientationOrientation (mental status)(mental status)
To time, place and personTo time, place and person
Brief assessment Brief assessment
6464
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements
Mood and affectMood and affect (mental status)(mental status)
eg, depression, anxiety, agitationeg, depression, anxiety, agitation
Brief assessmentBrief assessment
6565
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
9920599205 11stst 12 + 1 mental 12 + 1 mental
6666
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements (of 14, record all that (of 14, record all that apply)apply)
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination ElementsExamination Elements (of 14, record all that (of 14, record all that apply)apply)
13. Orientation 13. Orientation (mental)(mental)
14. Mood and affect 14. Mood and affect (mental)(mental)
6969
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination, ScoringExamination, Scoring
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)
9921599215 11stst 12 + 1 mental 12 + 1 mental
7070
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Examination, ScoringExamination, Scoring
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
For Established Patient, most casesFor Established Patient, most cases
Examination Level = level of EMExamination Level = level of EM
7373
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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)
7575
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Medical Decision Making elementsMedical Decision Making elements
a) Diagnosis & Management Optionsa) Diagnosis & Management Options
b) Complexityb) Complexity
c) Riskc) Risk
7777
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
1997 DG1997 DG Diagnosed problem decisions are Diagnosed problem decisions are easiereasier
Un-diagnosed problem decisions are Un-diagnosed problem decisions are harderharder
7979
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
1997 DG1997 DG Need to seek advice from others Need to seek advice from others indicates complexityindicates complexity
8181
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
Choices for gradingChoices for grading
NoneNone
MinimalMinimal
LimitedLimited
MultipleMultiple
ExtensiveExtensive
8282
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Want help to grade ??Want help to grade ??
8383
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Diagnosis & Management OptionsDiagnosis & Management Options
Exam form Exam form ““DiagnosisDiagnosis”” section, add: section, add:
““New – chronic – improved – stable – worseNew – chronic – improved – stable – worse””
8787
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Medical Decision Making elements Medical 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)
8888
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
ComplexityComplexity
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
![Page 91: Determine Level of 99 Code 1. EM Rules in CPT Manual 9 pages, starting pg 4, CPT 2013 EM Rules by Medicare 15 pages of 1995 Documentation Guidelines (DG)](https://reader037.vdocuments.mx/reader037/viewer/2022110209/56649e545503460f94b4a923/html5/thumbnails/91.jpg)
Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
ComplexityComplexity
Choices for grading areChoices for grading are
MinimalMinimal
LimitedLimited
MultipleMultiple
ExtensiveExtensive
9191
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Want help to grade ??Want help to grade ??
9292
![Page 93: Determine Level of 99 Code 1. EM Rules in CPT Manual 9 pages, starting pg 4, CPT 2013 EM Rules by Medicare 15 pages of 1995 Documentation Guidelines (DG)](https://reader037.vdocuments.mx/reader037/viewer/2022110209/56649e545503460f94b4a923/html5/thumbnails/93.jpg)
Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
ComplexityComplexity
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
ComplexityComplexity
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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)
9595
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
RiskRisk
1997 DG1997 DGDetermination of risk is complex and Determination of risk is complex and
not readily quantifiablenot readily quantifiable
9898
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Grading Overall MDMGrading Overall MDM
104104
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
For New PatientFor New Patient
Lowest between Exam and MDM = Lowest between Exam and MDM =
level of EMlevel of EM
106106
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Big PictureReview of Big Picture
b) Established Patientb) Established Patient
Examination Level = level of EMExamination Level = level of EM
108108
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
Review of Big PictureReview of Big Picture
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
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Determine Level of 99 Determine Level of 99 From Chart DocumentationFrom Chart Documentation
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
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CPT examples of EMCPT examples of EM
Appendix C of CPT manualAppendix C of CPT manual
111111
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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CPT examples of EMCPT examples of EM
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
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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