Cohen Bruce H, Busis Neil A, Villanueva Raissa, Ciccarelli Luana
Continuum (Minneap Minn). 2020 Dec;26(6):1686-1697. doi: 10.1212/CON.0000000000000953.
Medical services can be conceptualized as falling into two categories: procedures and cognitive care. A procedure is defined as a surgical, medical, or diagnostic test performed on a patient, such as an x-ray, wound suture, surgery, or physical therapy treatment. Cognitive care, also known as Evaluation and Management (E/M) services, involves performing a medical history along with a physical examination and possibly ordering or reviewing diagnostic tests before formulating a medical opinion and initiating a care plan. The uniform language and categorization of all medical services is contained in the Current Procedural Terminology (CPT) manual by the American Medical Association, which precisely describes all medical services using non-overlapping definitions and descriptions. The codes defined by CPT are the most commonly accepted set of codes used to file medical claims. In 2000, the US Department of Health and Human Services designated CPT to be the national reporting standard used in conjunction with the Health Insurance Portability and Accountability Act (HIPAA). CPT codes used today for E/M services were established in 1995 and define the components of history, examination, and medical decision making necessary to determine the level of each cognitive care service as delivered by a physician or other qualified health care professionals (eg, advanced practice providers). E/M rules were modified in 1997 and allowed some specialty services, such as neurology, to substitute a single system examination for a general, multisystem physical examination. Although new E/M codes were added over the years, the code descriptions and documentation guidelines for E/M services for outpatient and inpatient care remained essentially unchanged from 1997 through 2020. Most of the work performed by neurologists is E/M services, and the rules for coding outpatient care will change dramatically on January 1, 2021. This article discusses the rationale for these coding changes and explains how they are to be applied in the clinical setting.
手术操作和认知护理。手术操作被定义为对患者进行的外科、医学或诊断性检查，如X光检查、伤口缝合、手术或物理治疗。认知护理，也称为评估与管理（E/M）服务，包括采集病史、进行体格检查，并可能在形成医学意见和启动护理计划之前安排或复查诊断性检查。所有医疗服务的统一语言和分类包含在美国医学协会的《现行程序术语》（CPT）手册中，该手册使用不重叠的定义和描述精确地描述了所有医疗服务。CPT定义的代码是用于提交医疗索赔的最常用的一组代码。2000年，美国卫生与公众服务部指定CPT为与《健康保险流通与责任法案》（HIPAA）一起使用的国家报告标准。如今用于E/M服务的CPT代码于1995年确立，定义了确定医生或其他合格医疗保健专业人员（如高级执业提供者）提供的每项认知护理服务水平所需的病史、检查和医疗决策的组成部分。E/M规则于1997年进行了修改，允许一些专科服务，如神经科，用单一系统检查替代全面的多系统体格检查。尽管多年来增加了新的E/M代码，但从1997年到2020年，门诊和住院护理的E/M服务的代码描述和文档指南基本保持不变。神经科医生进行的大部分工作是E/M服务，门诊护理的编码规则将于2021年1月1日发生巨大变化。本文讨论了这些编码变化的基本原理，并解释了它们在临床环境中的应用方式。
