Lecture 1

What is the CPT code >

A CPT code (Current Procedural Terminology code) is a five-digit code that describes medical, surgical, and diagnostic services and procedures provided to a patient, developed by the American Medical Association (AMA).

Describe the 1988 CPT code changes?

AMA, HFCA, CPT Editorial Panel, CPT Advisory Committee, the Practicing Physicians Advisory Council, and the medicare carrier directors begin work to revise or replace existing E/M codes

Describe the 1992 CPT code changes?

F and M section of CPT overhauled with all new E/M codes

Describe the 1995 CPT code changes?

documentation guidelines for E/M services joinly developed by the ama and hcfa

Describe the 1997 CPT code changes?

AMA and HCFA release revised documentation guidelines for evaluation and management services to be effective January 1, 1998

Describe the 1998 CPT code changes?

1998 E/M DGs postponed indefintely. Physicians instructed to use 1995 DGs or 1997 DGs

AAOx4

Awake

Alert

Orientation

-Place (where are you?),

-Time (what year is it?),

-Person (Who is president?),

-Purpose (Why are you here?)

FD12

Involuntary hold in the department until accepting hospital becomes available

NPO

Nothing per orifice/oral (no water or drink), it could delay process

in the ED- who's in the main side? (core)

-Sickest in department

-People who get radio notes

-Stroke, heart attack, appendicitis, cholecystitis, etc

In the ED- whos in the Fast Track (FT), Urgent Care (UC), Minor Side?

-Non life threatening

-Cold, sore throat, pain to shoulder, viral infections

Result Waiting Room (RWR)

-Tests done and waiting on results

-Do not require a room yet

How many ESI levels are there?

•5 levels - life threat goes back first

ESI 1

. CPR in progress, shock (low BP), obvious life threat

ESI 2

•myocardial infarction (heart attack, stroke, anaphylaxis, extremely elevated heart rate)

esi 3

•Pain with unknown cause (gastritis, appendicitis, ?- we do not know).

•Could be promoted or demoted based on findings

ESI 4

•. Simple complaint- need a test (pregnancy status), twisted angle, cut while cooking.

•No need for a MASSIVE workup, minor workings to treat these patients (strep test, covid test, etc)

ESI 5

•Nothing wrong- prescription refill, (back pain with no medication)

Urgent Care- what kind of patient goes therE?

nPatient with lower acuity

nESI

nPatients Who do not require complex medical decision making

Critical Care Rooms-

equipped with equipment to treat patients with life threats)

Trauma Rooms

-white

-yellow

(white- non serious, yello—serious)

Isolation Room:

: negative pressure room

light gray scrub

radiology

PCT color scrub

pewter gray

procedural color

ceil blue

rehab color

black

transporter color

teal blue

phlebotomist color

wine

dietitian color

royal blue

resp therapist color

hunter green

medical student color

light green

nurse scrub color

navy blue

who wears eggplant color

sitter