Alright so I’m going to take this first question. This was one… actually, I got twice this week so I said alright. There’s an EM practice board exam question out there, I won’t say where. I reworded it so I don’t get in trouble. But two different people emailed me about it. So I said, “Okay, I’m going to go over this.” So here’s the question: A 60-year old woman comes in for a second opinion for her sleep apnea. The physician documents an extended history. She’s had it for the past 4 months. Sleep is disrupted by frequent awakening and getting worse by anxiety and snoring. Current medication that she is now on is not helping. An extended review of systems indicate she feels tired all the time, has some joint stiffness and night sweats. She is going through a divorce. Doctor performs a comprehensive exam and moderate medical-decision making.
EM Practice Board Exam Question Video
So this is from students who have either taken my Blitz or the course and I teach a method, Locate your HEM in time which basically is saying… well first, identify the location or the category and subcategory of E&M. And in this case, the answers are 99203 and 204 which are office new patient codes. And then 214 is an established and 243, I think, is a consult. So because they’re coming in for a second opinion, we can cross off C and D. Okay so it’s now going to be 203 or 204 and that’s the tie breaker that we want to try and figure out.
So here’s my little worksheet. I tell you to write on your exam booklet or even in the real coding world, on your you know, whatever… wherever you’re keeping notes, Locate and HEM. And the goal is to fill in the blank to the right. So for location, we’ve identified it as office new.
For the history, they didn’t really come out and give us the history which often times, in the board exam, they will do. But it did say the physician documents an extended history. Well, for history and exam, they have problem-focused, expanded problem-focus, detailed and comprehensive. So extended isn’t one of those terms. So they technically did not provide outright with the overall history level is. But for exam, they did. They said comprehensive exam and moderate medical decision-making. So I put a C for the exam and I put an M for moderate decision making for the medical decision making.
Now when you look in your CPT book, in the E&M section for office new, you’d see that the C shows up on the level 5 or 99205. So for shorthand, we just put a 5. And the moderate medical decision making shows up at a level 4. So so far, these are the two levels. We need to figure out what the history is because for office new, we know that we need to meet or exceed all 3 of the bullets for that exam.
So what this is doing is it’s making us work for the history. So for the history since we have to work for it, we need to turn to our history table that you hopefully wrote in your manual. And you know what? Let me see if I can get my document camera up for that.
Alicia: While she’s doing that, I was going to mention, this is classic for board exams. They’re wanting you to… they know you know how to find codes but can you pick the right code? By having to come up with the history, that shows them that you know how to pull the history out of your documentation and pick the correct code.
Laureen: Okay so this is my page 3 of my CPT manual which you know, if you do the Blitz or the course, you’ll get a copy of this. This is what you want to write in your worksheet and we’re trying to fill in these blanks. Okay, that’s what I’m trying to do on the slide. So since we’re trying to figure out history, I’m going to go to the history table that I wrote in and this is basically taking the… let me back up here just a little bit.
Alicia: I want to say I think you can make it smaller.
Laureen: Yeah, that’s what I’m doing. How’s that?
Laureen: Okay so I’m a very visual person as you’ve heard me say many times before, if you’ve listened to me on these videos because when I see paragraphs of text, it’s like Charlie Brown. I’m just not getting it. So I have to convert things to a visual. So all of this table is from the guidelines in the pages that preceed this. So I just took history present illness, I turn to the definition for HPI and I saw that there were 2 possible scores. Okay, you see that extended so that should look familiar. So an HPI, history present illness can be either brief or extended. Well, they told us it was an extended, right?
Okay so the next piece of history is review of systems. And you can have no review of systems done. You can have a problem pertinent which is basically one system, problem pertinent that’s extended, that 2 to 9 or complete which is 10 to 14 systems. Now, review of systems sounds a lot like the exam because you’re talking about cardiovascular, genito-urinary. So it sounds like things that you would examine. But it’s what I call the talking, not the touching. It sounds a little perverted but they’re asking the question… the patient questions about those organ systems because it’s something that they can’t measure or palpate or you know, weigh. They have to find out you know…. well you know, are you having headaches too? You know, that kind of thing. They can’t look at you and see that you’re having a headache. You have to tell them.
And then the 3rd piece to history is the past family social history or someone recently said, “Oh PFSH.” Like okay, whatever works. But there’s 3 distinct pieces, past history, family history and social history. So if you see documentation for one or two of those, it’s considered a pertinent PFSH. All 3, it’s considered a complete.
And then here’s the 4 possible levels that we want to fill in on our H line down here, P E D C – problem-focused, expanded-problem focused, detailed or comprehensive. Okay so they’re making us work for it on the slide, let me go back there real quick. Are you still seeing my book or are you seeing the slide?
Alicia: Yeah, we’re seeing the book.
Laureen: Oh okay. How about now?
Alicia: There we go, back to the slide.
Laureen: Okay so… there we go. So the HPI is extended. The ROS was extended. The past family social history is pertinent because when you read about it, it was just really talking about she’s going through a divorce. Okay so when you go back to the table, we’re trying to plug in, extended, extended pertinent. And the extended we’ll see will come out to a C. The extended ROS comes out to a D and the pertinent comes out to a D. So let’s see how that works out. Extended, extended, pertinent. Alright so here’s extended, here’s extended and here’s… that’s not what I was looking for. What did I say? One of them came out to a C. Oh okay, here we go.
So since extended on this one, it shows up on both levels, we always give them a higher one. We always give them the most credit that we possibly can that they document it. So that’s why the HPI is going to get a C. Okay but the extended for ROS only shows up at this row so they get a D and then the pertinent gets a D. And when you put that all together, since this is a 3 of 3 table, the lowest wins. And the lowest in this case is going to be the detailed. Alright?
So now we come along and now we can… where we had not provided out right, we figured it out. It’s a D, it’s a detailed. And when we turn to the 99203 and 4 code, we can see when it’s 3 of 3, we code to the lowest. So what’s the lowest between a level 3, 4, and 5? The level 3. Okay so the answer to this case is 99203. The reason this kept coming to me is they had it wrong in the answer key. They were telling them it was B or it was 99204. So that’s where the confusion was coming and they thought they were doing this pattern correct but how they tricked them was they used this extended history. And they’re thinking, “Oh, E-extended.” But it’s actually expanded problem-focused history. So you had to go back and really look at it closely and use that table.
So for those who haven’t taken their certification exam, the heads up for you is that it used to be… there’s about 10 questions on E&M on the board exam. About 2 of the 10, I used to say, they make you work for it. Now I’m hearing it’s more like 4 to 5 of the 10. So definitely make sure you write your tables in and your CPT manual so you can use them to help you figure out the missing slot.