If you know this jargon, you'll get through your claims quota faster
When I first came face to face with the acronyms, abbreviations, and mumbo-jumbo jargon that come along with E/M coding, I felt like this ostrich must feel: Out of place and unsure of what to do next.
So here is a reference guide to E/M terminology that will help you out when you are stuck in such a situation.
CC: refers to Chief Complaint. This is a brief statement by the patient which explains the main reason for the visit to the doctor. The next step is to look for a symptom, condition and diagnosis.
Dx: Refers to Diagnosis
Hx: Cites History
HPI: expands to History of Present Illness: The following areas are the determinants of HPI:
1. Location: the place on the body of the patient where the symptoms prevails.
2. Context defines what the patient was doing when the problem first occurred.
3. Quality represents the signs or symptoms. For example, if a patient complaints of a sharp pain in her shoulder, -sharp- is the quality.
4. Timing is the time of day when patient experienced the signs or symptoms. For ex- a patient felt a pain after standing for long periods, last two week. Here the timing is "After standing for long periods".
5. Severity shows the seriousness of the patient's condition. Severity is indicated by a scale of 1 (least painful) to 10 (most painful).
6. Duration shows for how long the patient's signs and symptoms were present.
7. Modifying factors are the measures that the patient took to alleviate pain (for example, - Pain improved when patient sat for 15-20 minutes or patient's low back pain was worsened by continuing to stand for long periods).
8. Associated signs and symptoms are any other problems the patient suffers from apart from the chief complaint (such as blurred vision, an associated symptom of migraines).
The physician must cover and document in the HPI documentation a minimum of four of these points.
MDM: Medical Decision Making: The decision making process of the doctor, after taking into account the risks involved.
PFSH: Past Family and Social History
"Past history" can be medical, surgical or any other personal history.
"Family history" includes medical events of the patient's family.
"Social history" reviews the individual's current and past activities. Smoking history, alcohol history is a few examples.
ROS: Review of Systems: An ROS is a list of symptoms asked by the patient which helps the physician in establishing a diagnosis.