How to Dissect an E&M Service History and Physical How to Dissect an E&M Service: History and Physical PMI Online Education

S.O.A.P. S.O.A.P. Most reports follow the note format Recognize the SOAP note format Assign these components History Physical Exam Medical Decision-making Most reports follow the S.O.A.P. note format Coding an E&M service can be daunting at first glance. Most reports are dictated following the SOAP note format. Good abstraction begins with recognizing this format and assigning the history, physical examination, and medical decision making components to each section.

S O A P S.O.A.P. Chief complaint Patient history Review of systems ubjective Chief complaint Patient history Review of systems O bjective This tutorial will: Explain abstraction process Define the components Physical examination Lab data findings Work performed to determine level of PE Necessary for MDM A ssessment Consider the relationship like this:   Subjective: This includes the Chief Complaint, patient history, review of systems. Objective: This represents the physical examination, lab data findings, and any work performed to determine the level of PE (physical examination). Assessment: This portion gives the coder the number of diagnosis and the degree of mortality and morbidity. Both are necessary for the medical decision making component. Plan: This often details the management options the physician will apply to this patient. This presents the final element for determining the level of medical decision making. This tutorial will walk you through the abstraction process step by step and help you define the components. Number of diagnosis Degree of mortality and morbidity P lan Management options Final element

HISTORY 99201 99202 99203 99204 99205 E&M Selection: Page 1 HISTORY E&M Selection: 99201 99202 99203 99204 99205 Detail elements pertinent to PFSH Patient status: New Place of service: Office/outpatient Remaining complaints detail: Personal history Presenting diagnosis Current management options This statement gives the patient status, which is new, and the place of service, which can be considered office or outpatient. This narrows the E&M selection to just five. (99201-99205) The remaining chief complaint details personal history, presenting diagnosis, and current management options. These help define the history and medical decision making components. This information here details elements that are pertinent to Past, Family, and Social History.

Should be part of the intake paperwork for a new patient Page 1 HISTORY E&M Selection: 99201 99202 99203 99204 99205 While unremarkable, the Review of Systems (or ROS) are covered by this statement and should be part of the intake paperwork for a new patient. This completes the history component at a comprehensive level. Should be part of the intake paperwork for a new patient

PHYSICAL Understand the elements required for the physical exam Page 2 PHYSICAL Understand the elements required for the physical exam (vitals, general appearance, HEENT) 9 or more OS/BA Make sure you understand the elements required for the physical exam. The vitals and general appearance remark represent two elements. The reference to “HEENT” covers 4 more: head, ears, eyes, nose, and throat.   The remaining narrative covers at least 9 more OS/BA (organ systems/body areas). This justifies a comprehensive level of PE (physical examination).

PHYSICAL Remember the glucose logs mentioned in the CC Page 2 PHYSICAL Gives the management options and test data to be reviewed by physician Remember the glucose logs mentioned in the CC These diagnoses give the number of presenting problems in determining the level of risk Make sure that you know the components of MDM. These diagnoses give the number of presenting problems in determining the level of risk. There are 2 chronic but stable issues mentioned here. The plan gives the management options and test data to be reviewed by the physician. There are 3 separate test results to review and one referral. Remember the glucose logs mentioned in the CC. This equates to a moderate amount of data to review.

Risk of Mortality/Morbidity While this patient has a number of potential serious issuses… Level of Risk: Moderate Overal Comlexity: Moderate He is somewhat stable at this time Finally, the risk of mortality/morbidity. While this patient has a number of potential serious issues, he is somewhat stable at this time. The appropriate level of risk should be moderate while the overall complexity of medical decision making should also be moderate.

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