Clinic Visit Types
This type of visit begins with a chief complaint.
What is a Problem Visit?
A "kind" of test commonly ordered during a wellness visit for an asymptomatic patient.
What is screening?
Immunizations and related counseling are part of which visit?
What is Wellness?
Documentation required to support high risk for parenteral controlled substances.
What is the route and the medication?
X7499, Email, Teams, Secure Chat
What are ways to contact my CDES?
This type of visit is for a patient recently discharged from the hospital with a moderate or high risk for re-admission.
What is Transitional Care Management?
RN phone call, days since discharge and medical decision-making.
What are the 3 elements required to bill TCM codes?
The minimum level of MDM to support a split bill.
What is LOW MDM (99203/99213)?
How to support review of labs for determining level of medical decision-making.
What is describing results in words?
The day your CDES is usually in clinic.
What is Thursday?
This visit type includes an age- and gender-appropriate history and exam, counseling on preventive measures and ordering of screening tests.
What is Wellness (or Prevent Med)?
Diet, substance use and injury prevention.
What are topics for counseling at a wellness visit?
A reason to explain split billing to a patient.
What is "patient experience" or "managing patient expectations"?
This is an example of how NOT to document a discussion with a neurologist during an inpatient stay.
What is "neuro consulted"?
This is what "establish care" tells you about a patient's appointment.
What is "they are new"?
A common "visit type" that does not have CPT codes associated with it.
What is Establish Care?
Codes used when TCM MDM is low?
What are 99203 & 99213?
Three criteria for split billing a visit.
What are separately identifiable, significant, and additional documentation (assessment & plan)?
Best practice to support high risk for medications that are may quickly become toxic.
What is documenting monitoring in the note?
This code represents the work of maintaining a long-term relationship with a patient.
What is G2211?
The two main types of wellness visits for patients over age 65 with government insurance.
What are Welcome to Medicare and Medicare Annual Wellness (MAW)?
This element is often missing from a Welcome to Medicare visit.
What is visual acuity?
Phrase documented to support billing only a wellness visit when a minor problem is addressed.
What is "minimal time was spent addressing the problem today"?
Three things that Int Med Residents have documented really well.
What is documentation to support analysis of tests, parenteral controlled substances and daily MDM on inpatient rounding?
The next step after updating your note.
What is re-route to the attending?