# Elements/Bullets in CPT book itself?



## bethybb (Jul 26, 2010)

Although I understand the E/M coding process, it just feels like quadratic equations to count bullets, elements, etc. without a guide sheet.  I have some great resources for figuring out levels, required elements, but I can't take those into the exam with me.  Are there lists of the elements in the CPT book itself that I am just missing?  Mine is the "standard" edition by the AMA.  The only listings I see are the body systems, organ systems, and MDM graph.

For example, an extended HPI requires 4 or more elements (location, quality, severity, etc.), or the status of 3 chronic or inactive conditions.

Besides my curriculum text and my "cheat" sheets, where do I find the HPI element(s) listing?  Where do I find the "4 or more" notation?  I'm sure I'm not allowed to write a graph into my book with these guidelines, but I can't find them in the CPT book.  

Appreciate any help


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## khswain (Jul 27, 2010)

I just proctored a CPC exam 2 weeks ago, and I happen to still have in hand the rules for doing book checks.  Quoted from the Instructions for AAPC Exam Proctors sheet: "Tabs can be inserted, taped, pasted, glued or stapled in the manuals, if the obvious intent is to earmark a page with words or numbers and not add supplemental information.  No other material of any kind may be taped stapled or glued into the manuals to be used during the examination.  *Handwritten notes in coding books (as those commonly seen in daily work coding activities) are permitted.  Manuals will not be disqualified due to writing cotained therin*."  So my suggestion... if you have something that works great for you feel free to write it in there as it will not be disqualified!

Good Luck!  
Katrina H. Swain, CPC


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## LLovett (Jul 27, 2010)

*Which exam?*

If you are taking the CEMC, yes you can take your audit sheets with you.

If you are taking the CPC I don't think you will need them. Its been awhile since I took my CPC but unless they have changed I didn't actually audit any E/M. They told you it was a detailed history, expanded problem focused exam, and mdm was moderate. Then you pick which E/M was supported by those levels based on the scenario.

Good luck,

Laura, CPC, CPMA, CEMC


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## Lisa Bledsoe (Jul 27, 2010)

bethybb said:


> Although I understand the E/M coding process, it just feels like quadratic equations to count bullets, elements, etc. without a guide sheet.  I have some great resources for figuring out levels, required elements, but I can't take those into the exam with me.  Are there lists of the elements in the CPT book itself that I am just missing?  Mine is the "standard" edition by the AMA.  The only listings I see are the body systems, organ systems, and MDM graph.
> 
> For example, an extended HPI requires 4 or more elements (location, quality, severity, etc.), or the status of 3 chronic or inactive conditions.
> 
> ...



You can write anything you want in your book.  If you are taking the CEMC you can bring the 95 and 97 guidelines as well as audit tools.


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## Lhaley (Jul 27, 2010)

I just took the CPC exam last week and I have notes all over my books.  I did have the E&M notes written in the book as well and it wasn't a problem.  WhenI took the course I used my books to take notes into.
Good Luck!


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## SCanterbury (Jul 27, 2010)

You have to realize that the Evaluation and Management Documentation Guidelines published jointly by CMS and CPT in '95 and '97 contain information more specific (and in a few instances slightly different) than the Evaluation and Management Services Guidelines appearing before the E/M code section in the CPT book.

The CPC exam typically does not require you to use the more advanced detail from the '95 or '97 Guidelines. For example, the CPT book E/M Guidelines lists 7 components of HPI in the "History of Present Illness" section. In the "Determine the Extent of History Obtained" section, you'll note that the HPI is either called a "limited" HPI or "extended" HPI.

The more detailed '95 and '97 Guidelines actually list 8 components of HPI (they include duration as a separate HPI component from timing). They also define a "limited" HPI as 3 or less HPI components/elements, and an "extensive" HPI as being one in which 4 + elements are addressed. The CPT book does not do this, and I'll stress again that the CPC exam typically tests only the information included in CPT.

Now if you are taking a more advanced E/M coding or auditing certification, this more detailed knowledge may be necessary, but they will also usually let you bring copies of the '95 and/or '97 Guidelines into the exam when that is the case.

Seth Canterbury, CPC, ACS-EM


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## bethybb (Jul 27, 2010)

Thank you so much everyone!


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## KellyLR (Aug 1, 2010)

*Standard Edition....*

Bethy,

I did away with the Standard Edition after the first time I bought it several years ago.  I only use the Professional Edition of the CPT.

Best Regards



bethybb said:


> Although I understand the E/M coding process, it just feels like quadratic equations to count bullets, elements, etc. without a guide sheet.  I have some great resources for figuring out levels, required elements, but I can't take those into the exam with me.  Are there lists of the elements in the CPT book itself that I am just missing?  Mine is the "standard" edition by the AMA.  The only listings I see are the body systems, organ systems, and MDM graph.
> 
> For example, an extended HPI requires 4 or more elements (location, quality, severity, etc.), or the status of 3 chronic or inactive conditions.
> 
> ...


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