Chief Complaint: the reason for seeking medical care is stated by the patient in the patient’s own words.

Comprehensive: refers to the highest level of history or examination reportable under the E&M service codes.

Concurrent Care: the provision of similar services, eg. Hospital visits, to the same patient by more than one physician on the same day.

Counseling: refers to the act of providing professional advice and/or instruction to the patient and/or patient’s family regarding patient’s condition and plan of care.

Consultation: when a physician responds to a request from another provider for a medical evaluation, opinion and plan of treatment, renders an opinion, and reports the outcome to the requesting provider.

Coordination of Care: time spent by a provider arranging for follow-up treatment, care, consultations and other services not typically provided by the provider making these “arrangements.”

Critical Care: the direct delivery of medical care to a patient who is either critically injured or critically ill.

Detailed: the description used to identify a level of history or examination performed through the course of an E&M visit.

Domiciliary: pertains to the long-term care setting where the patient is living in an institutional setting with minimal assistance for daily living.

Established Patient: a patient who has been seen by a provider or a fellow provider from the same specialty of the same group practice within the past 3 years.

Expanded Problem Focused (EPF): a description used to identify a level of history or examination performed during the course of an E&M visit.

Face-to-Face Time: the time spent face-to-face between the provider and the patient.

Floor Time: time spent by a physician caring for a patient in the inpatient arena that is not “face-to-face”, performing duties such as researching test results, coordinating care or therapies with other departments, counseling family members and writing patients’ orders.

High Severity: the risk of morbidity without treatment is high to extreme.

History of Present Illness (HPI): a description of the patient’s illness in a chronological order from onset of first symptoms until the present.

Low Severity: a problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.

Minimal Severity: constitutes a problem that may not require the presence of the physician; however, service must be provided under the physician’s supervision.

Moderate Severity: the risk of morbidity without treatment is moderate, or an uncertain prognosis exists.

Nature of Presenting Problem: a disease, condition, illness, injury, symptom, sign, finding, compliant or other reason for encounter with or without a diagnosis being established at the time of the encounter (minimal, self-limited, low, moderate or high severity).

New Patient: one who has not received any professional services from the physician, or another physician of the same specialty from the same group practice within the past 3 years.

Observation: evaluation of a patient for a condition that is not serious enough for admission to the hospital but where the patient is not well enough to be at home.

Patient History: information communicated to the provider from the patient which identifies the chief complaint, history of present illness, review of systems, and the past, family and social history as the components of the patient history.

Preventive Care: care which is rendered in times of good health to ward off or prevent ill health from happening or existing unchecked. It is based upon the age of the patient and whether he is new or established to the practice.

Problem-focused: a brief history of present illness along with a chief complaint and/or an exam limited to affected body area or organ system.

Review of Systems (ROS): an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

Self-limited problem: a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

Unbundling: the billing of multiple procedure codes for a group of procedures that are covered by a single comprehensive code.