RCM

Hospital Staff

MD
DO
NP
PA
RN
Medical Scribe
Medical Student
Resident

Payors
Govt Payers
Medicare
Medicaid
Tricare
Champua
Colorado
Self pay with greater than 65 years considered as Govt payer

Patients
New patients
Who didn’t saw within 3 years by same physician or different physician of same department/Group

EM
Face to face visit patient /physician interaction for patinet health care and service provid

Types
E&M
Office (outpatient ) visits
Inpatient visits
Emergency department
ED Observations
Consultations (IP, OP)
Home health
SNF
 Outpatient office visits

New
99202
99203
99204
99205

Basic EM Key components

History
Exam
MDM

History

PE

MDM
Table A
NOPP
Starightforward (Minimal_)
Low
Moderate
High

1 Self limited Minor problem

Self-limited or minor problems are those

that typically resolve on their own within
a predictable timeframe and don't require
extensive medical intervention, like a
simple cold, a minor rash, or a bug bite.

Here's a more detailed breakdown of

examples:

Common Examples:

Minor Skin Issues

Insect bites

Simple rashes
Minor abrasions

Hangnails
 Mosquito bite

Viral illness
Simple rash

Follow-up on resolved issues

Uncomplicated pharyngitis

Uncomplicated cold
Allergic rhinitis/ hay fever

Minor abrasions
 Patient Payor

Licenced and registered

Licenced and registered
Licenced and registered
Licenced and registered
We should not bill RN
Not registered
Not registered
istered physician , we should not bill resident ,his document required Addendum by MD or DO

Private payers
Cigna
Aetna
BCBS
Commercial
etc
Self pay with greater than 65 years considered as Govt payer

Established patients
within 3 years by same physician or different physician of same department/Group

Evalution and Management

t patient /physician interaction for patinet health care and service provided by Physician
virtual (audio or vedio)

MDM Out patient office visits (with in 24 hours )

Types of patients
Procedures
Proffe, Facility Other visits like
telehelath (Medicine )
Preventive/Annual welness visits )
Consults

Inpatient (Greater than 24 hours )

Types of patients
Procedures
 Consultations

Emergency Department
With in 24 hours
Types of patients
Procedures

ED observations
Same day /Different day discharge

Home health services

SNF (Skilled nursing facilty )

Time / MDM

Established
99211
99212
99213
99214
99215

Councelling
Coordination of care
Time
NOPP
CC Reason for visit
HPI
ROS
PFSH
1995 or 1997

Medical decision Making

Table B Table C
ACD CRF

New Problem:
 If the condition requires prescription drug
management or further medical investigation,
it's likely a new problem and not a self-limited
one.

1 Stable chronic illnes Acute uncomplicated injury/illness

Stable chronic illnesses are conditions that Acute uncomplicated illnesses or injuries are
persist for a year or longer, requiring ongoing recent, short-term problems with low risk of
management but generally remain stable in morbidity, expected to resolve without
severity, with examples including well- residual impairment, and may include
controlled hypertension, non-insulin-dependent conditions like cystitis, allergic rhinitis, or a
diabetes, and asthma. simple sprain.

Here are some examples of stable chronic illnesses: Infections:

Hypertension (high blood pressure): Urinary tract infections (UTI)

A condition where blood pressure consistently
remains elevated, which can be managed with Sinusitis
medication and lifestyle changes.
Diabetes: Sore throat

A condition where the body either doesn't produce

enough insulin or can't effectively use the insulin it Ear infections
produces, leading to high blood sugar levels.

Asthma: Cystitis
A chronic respiratory disease characterized by
inflammation and narrowing of the airways, often Allergic rhinitis (hay fever)
managed with medication and inhalers.
 Obesity: Pink eye (conjunctivitis)
A condition characterized by excessive body fat,
which can be managed through lifestyle changes Injuries:
and, in some cases, medication or surgery.
Arthritis:
A condition causing inflammation and pain in the
joints, which can be managed with medication and Simple sprains
physical therapy.
Type 2 Diabetes: Minor bruises
A chronic condition where the body becomes
resistant to insulin, leading to high blood sugar Insect bites
levels.
Alzheimer's Disease: Tinea corporis (ringworm)
A progressive neurodegenerative disorder that Colds
causes memory loss and cognitive decline.
Chronic Kidney Disease: Other:
A condition where the kidneys gradually lose their
ability to filter waste from the blood.
Coronary Artery Disease: Flu
A condition where the arteries that supply blood to
the heart become narrowed or blocked, potentially Rotavirus
leading to a heart attack.

Depression: Broken bones (in some cases, depending on

severity)
A mood disorder characterized by persistent sadness
and loss of interest in activities, which can be
managed with therapy and medication.
Alcoholism:

A chronic disease characterized by compulsive

alcohol use despite negative consequences, which
can be managed with therapy and medication.

Arrhythmia:
An irregular heartbeat, which can be managed with
medication or other treatments.
 Physician RCM

Coding
Billing
AR

POS 11

POS 21
 POS 23

Profee Facility

POS 23

SOAP Subject
object
Assesment
Plan
Established Problem:
 If a problem is already known to the
provider and is either stable or improving,
it's an established problem, not a new or
self-limited one.

Acute, uncomplicated illness/injury requiring

Stable acute illness
hospital
A "stable, acute illness" in medical An acute, uncomplicated illness or injury that
decision-making refers to a recent or new requires hospital inpatient or observation care
problem for which treatment has been is a short-term problem with a low risk of
initiated, and the patient's condition is serious illness or death. It's a condition that
improving and considered stable, even if usually resolves on its own, but isn't improving
full resolution is not yet achieved. as expected.

Examples of acute illnesses include viruses Examples of acute, uncomplicated illnesses or

like the flu, broken bones, and infections injuries Uncomplicated appendicitis, Cystitis,
like urinary tract infections or pink eye. Allergic rhinitis, Simple sprain, and Influenza.
MDM
MDM
 Chronic w/exacerbation, progression or side effects
of treatment

A chronic illness with exacerbation, progression, or side

effects of treatment is a condition that's worsening or
progressing, and may require hospitalization. It can also
mean that the treatment is causing side effects that need
attention.

Examples Cancer progression during treatment, Proctitis

during radiation treatment for prostate cancer, and
Exacerbations of chronic obstructive pulmonary disease
(COPD).
EM IP or OP
 undiagnosed new problem with uncertain prognosis

An "undiagnosed new problem with uncertain prognosis" in medical coding refers to a

situation where a patient presents with a new symptom or condition, but the underlying
cause or diagnosis is unknown, and the potential outcome is uncertain.

Examples:
A new, unexplained lump in the breast: This could be a potential sign of cancer, requiring
further investigation.
Persistent abdominal pain with a negative workup: The patient has abdominal pain, but
tests like CT scans or ultrasounds haven't identified the cause, leaving the prognosis
uncertain.
New cardiac arrhythmia with unclear cause: A new irregular heartbeat pattern with an
unknown underlying cause, potentially requiring further testing and management.
Slightly enlarged ascending aorta: namas.co says this may require further investigation to
determine the cause and severity.
Abdominal pain with work-up to rule out appendicitis or a bowel obstruction: Brown
Consulting Associates says this may fall into this category.
Leg pain with work-up to rule out a DVT: Brown Consulting Associates says this may fall
into this category.
A patient with persistently poorly controlled blood pressure for whom better control is a
goal: University of Rochester Medical Center says, even if the pressures are not changing
and the patient is asymptomatic, the risk of morbidity without treatment is significant.
Red, watery eyes and fatigue: AAPC says, if a provider has a suspicion that it could be
something worse, the differential diagnosis (e.g., infection, dry eyes, foreign object,
ocular injury) needs to be documented.
outpatient
Inpatient
Emergency Department
Ambuatory sur
 Acute illness w/systemic symptoms examples

Acute illnesses with systemic symptoms are

conditions causing widespread body effects and
pose a high risk of morbidity if left
untreated; examples include pneumonia, colitis,
pyelonephritis, and cellulitis

Examples of Acute Illnesses with Systemic

Symptoms:
Infections:
Pneumonia (lung infection)
Colitis (inflammation of the colon)
Pyelonephritis (kidney infection)
Cellulitis (deep skin infection)
Sepsis (life-threatening blood infection)
Meningitis (infection of the membranes
surrounding the brain and spinal cord)
11
21
23
24
 Acute complicated injury

An acute complicated injury, according to the American Medical Association (AMA), is an

injury requiring treatment that involves evaluating body systems beyond the injured organ,
extensive injury, multiple treatment options, or treatment options with a risk of morbidity.
Examples include fractures requiring cardiovascular or neurovascular evaluations, head
injuries with brief loss of consciousness, or multiple injuries.

Examples of Acute Complicated Injuries:

Fractures:
Fractures requiring cardiovascular and/or neurovascular evaluations.
Open fractures with contamination and risk of compartment syndrome.
Proximal femoral fracture.
Head Injuries:
Head injury with brief loss of consciousness.
Multiple Injuries:
Multiple injuries sustained in a single event.
Other Examples:
A fracture that is compounded with rocks and debris in the open wound.
An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or
injury with exacerbation and/or progression or side effects of treatment.
Concussion with loss of consciousness for more than 2 minutes.
 Chronic illness with severe exacerbation, progression, or side effects of treatment

Chronic illness with severe exacerbation, progression, or side effects of treatment

includes:

Cancer treatment that progresses

Proctitis that develops during radiation treatment for prostate cancer
A chronic illness that worsens acutely or is poorly controlled
A chronic illness that requires additional supportive care
A chronic illness that requires attention to treatment for side effects
A chronic illness that has severe side effects of treatment that have significant risk of
morbidity
Registration
preauthoruization, coding
billing
charge entry or Payment posting
If any denial / AR team will follo up with payer
 Acute/chronic illness/injury that poses threat to life
or bodily function

Acute and chronic illnesses and injuries that can threaten life or
bodily function include:

Acute myocardial infarction: A heart attack that can be severe

Pulmonary embolism: A condition that can be life-threatening
Severe respiratory distress: A condition that can be life-threatening
Progressive severe rheumatoid arthritis: A chronic condition that
can cause disability and early death
Psychiatric illness: Can be a threat to self or others
Peritonitis: An illness that can threaten life or bodily function
Acute renal failure: An illness that can threaten life or bodily
function
Abrupt change in neurologic status: An illness that can threaten life
or bodily function
Stroke: A condition that can threaten life or bodily function
Anaphylaxis: A condition that can threaten life or bodily function
Broken bone: An acute condition that can occur due to a chronic
condition like osteoporosis
Pyelonephritis: An acute complicated illness
Pneumonitis: An acute complicated illness
Colitis: An acute complicated illness
Diabetes: A condition that can cause or contribute to death
ent posting
m will follo up with payers