HCPCS codes

HCPCS codes

Since these PO cases were created, and not “authentic” records so they are not an entirely full patient record, thus some information may not be present that you would typically find in a patient encounter. However, there is enough information here to accurately assign procedure codes.

In this scenario, page one is a standard patient summary, or face sheet. We take note of things like that patient’s age, sex, etc. Also of importance, is the location, however you know this is a physician’s office record. In many cases you will need to determine if this is a new or established patient. The documentation on that will vary based on the type of EHR used. For the sake of this project, we are saying all patients are established.

What do you need to accurately assign an E/M procedure code:

You might remember from Chapter 7, there are some key criteria you need to know to accurately assign an E/M procedure code.

First question: What are the criteria for determining the level of service: 2/3 key components, 3/3 key components, time or other?

Our case is an established patient, so we need to meet 2/3 key components of a code to assign it.

This means, our code assignment is already narrowed down to the subsection within the E/M section to, Established Patient, 99211-99215.

What do you need to accurately assign an E/M procedure code:

Next question, What level of history was taken by the provider?

The history is designed to act as a narrative which provides information about the clinical problems or symptoms being addressed during the encounter. The history is composed of four building blocks:

Chief complaint (CC)

History of present illness (HPI)