Chapter 15 E/M – Flashcards

5 types Nature of presenting problem

Minimal

Self-limited or minor

Low severity

Moderate severity

High severity

Key components

Complete PFSH (established)

Complete PFSH ( new Patient)

7 Components Recognized

Perinent PFSH

Externded ROS

Complete ROS

ROS

Extended HPI

HPI Elements

Brief HPI

History: expeanded problem focused

History: comprehensive

History: Detailed

History: problem focused

straightforward

low complexity

moderate complexity

High complexity

4. The level of E/M service is based on: Documentation Key components Contributing factors All of the above

According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam. Problem-focused Expanded problem focused Detailed Comprehensive

What are the four levels of medical decision making complexity?

The code range for Home Services is ________.

What are the four levels of history type?

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?99284 99291 99283 99220

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused Expanded problem focused Detailed Comprehensive

An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination? Problem-focused Expanded problem focused Detailed Comprehensive

Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)

Counseling, coordination of care, nature of presenting problem, and time are considered: Levels of E/M service Key components Contributory factors Medical decision-making process

These elements would be part of the ________ history: employment, education, use of drugs. Past Social Family Any of above

The HPI must be documented in the medical record by: The physician Any office staff member The patient Any of the above

When a physician performs a preventive care service, the extent of the exam is determined by the: Age Gender Gender and age Length of time elapsed since last exam

The definition of low birth weight can be found in the notes for subheading ________.

The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.

The ________ is a statement describing the reason for the encounter and is a history element.

Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward. CPT Code:

CHART NOTE CC: Dizziness SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49. OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9. ASSESSMENT: Hypothyroidism (MDM was low). PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months. CPT Code:

CAPD CYCLER DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Mandy Horton ATTENDING PHYSICIAN: Ronald Green, MD This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out. The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.) CPT Code: