question

ROS is an acronym for what?

answer

review of systems

question

Enter the number of levels of service there are for initial hospital care codes? (Please enter the number, not the verbiage for the number.)

answer

3

question

Enter the number for how many hospital discharge codes there are. (Please enter the number, not the verbiage for the number.)

answer

2

question

Name two things that could be considered social history.

answer

Answers include: drug and alcohol use, smoker, occupation, marital status, sexual or drug history, etc.

question

What makes a patient a "new" patient vs an "established" patient.

answer

NEW patient has NOT been seen by any provider in the practice for three years. An ESTABLISHED patient has been seen by a provider in the practice in the past three years. A new patient has NOT been seen by any provider in the practice for three years. The time frame is very important.

question

Seven vital signs make up constitutional for an exam. Name three.

answer

temperature, pulse, respiration, blood pressure supine, blood pressure sitting or standing, height, and weight

question

Yes or no, does a patient have to be admitted tot he ICU to bill critical care?

answer

no

question

Name ONE of the "three R's" for consultation coding and billing.

answer

request, render an opinion, and report back to the requesting provider

question

Time is considered a key factor when determining level of service when 50% of the physician time is spent doing what?

answer

counseling

question

Name 3 of the 7 components that make up E and M codes.

answer

history, exam, medical decision making, counseling, coordination of care, nature of presenting problem, and time

question

T/F After a patient is evaluated, a management plan is implemented and recorded in the medical facility.

answer

true

question

T/F a new patient is one who has not received face to face care from their provider within 2 years.

answer

false- 3 yrs

question

T/F there are seven key components to choosing a level of E/M service.

answer

false-There are only three/3 KEY components: history, exam, and medical decision making.

question

T/F The lowest level of code for an office visit when you are charging for a problem focused new patient visit is code 99211.

answer

false

question

T/F The ROS is the part of the note in which the provider documents any body system(s) that might be affected by the chief complaint.

answer

fasle

question

T/F when time is used as a key component in billing an E/M service, the provider must document face to face time with the patient and how much time was spent counseling the patient with the family.

answer

true

question

T/F an incorrect place of service can result in a rejection by insurance carriers.

answer

true

question

T/F a 99233 is coded for a high level initial hospital care visit.

answer

false

question

T/F to code a preventative physical exam, the coder first must determine the level of history the provider has recorded.

answer

false

question

T/F The POS for an office visit is 23

answer

false

question

the _______ is the location whre care was rendered.

answer

POS

question

____________ services are services provided to a patient who is presenting for a well visit.

answer

preventative medicine

question

critical care codes are _____ based.

answer

time

question

codes ______ are used when a patient is admitted and discharged on the same date of service.

answer

99234-99236

question

________ a patient and/or family member usually involves treatment options and instruction on medicine.

answer

counsleing

question

a patient who has NOT received face to face services from a provider of the same specialty within the same group practice would be considered a(n) _______ patient.

answer

new

question

a patient who has received face to face services from a provider of the same specialty within the same group practice would be considered a(n) _______ patient.

answer

established

question

a(n) _______ is a service rendered by a provider when his or her opinion or expertise is requested by another provider or appropriate source.

answer

consultation

question

an organized hospital based facility that renders unscheduled episodic services to patients who require immediate attention is know as a(n)

answer

emergency department (ED)

question

for services to a neonate in the intensive care unit to be coded with a 99479, the birth weight of the infant must fall between ______ and _____

answer

1500 and 2500 grams

question

CH 3 CASE STUDY 1 Mrs. Edison was having trouble eating some of the foods the nutritionists had set up on her diabetic diet menu. Mrs. Edison talked with the nutritionist, who in turn called the doctor overseeing Mrs. Edison's care. The doctor and the nutritionist were on the phone, had a lengthy phone conversation, and decided to integrate a new menu that both of them felt would be more beneficial to Mrs. Edison and management of her diabetes. The doctor decided to bill for the telephone call even though the information discussed was not complex in nature, details had to be worked out, and a change to the care plan was necessary. The call length is 24 minutes. CPT code(s): _______

answer

Case 1—99443 Rationale: Phone call was initiated by the patient and was not the result of the recent visit with the doctor. Time was calculated at 24 minute

question

CH 3 CASE STUDY 2 Daisy, a 10-year-old girl, was very sick when she presented for an office visit at her pediatrician's office. She was running a high fever, was very lethargic, had swollen glands, and showed signs of dehydration because of the vomiting she had been doing the previous night. The doctor decided, after a comprehensive history and physical, that Daisy needed to be admitted to the hospital for lab workup, rehydration, antibiotics, and monitoring. Daisy's pediatrician stopped in to the hospital that evening to evaluate her condition and check on lab results. CPT code(s): ____________

answer

Case 2—99223 Rationale: Hospital admission includes all work done in the office on the same date of service as the admission

question

CH 3 CASE STUDY 3 Colin was having great difficulty living alone since his recent fall down the back steps of his house. His family decided that Colin should move to a skilled nursing facility (SNF), which he finally agreed to do. The physician at the SNF did a comprehensive history and physical. The medical decision making was of moderate complexity, and there was a very detailed plan of care implemented which would work on building Colin's strength and re-teaching him how to get around in a safer manner. CPT code(s): ___________

answer

Case 3—99305 Rationale: Initial nursing care facility encounter where a comprehensive history and comprehensive physical was performed. Medical decision making was of moderate complexity.

question

CH 3 CASE STUDY 4 Nick was riding his dirt bike and collided with a tree. The EMTs stabilized Nick at the scene and transported him to the nearest hospital. His doctor, Dr. Shanequa, had been contacted by the family and would meet them at the hospital emergency room. In the emergency room, Dr. Shanequa took a detailed history, did a comprehensive physical, and ordered lab work and x-rays of the head, neck, and back, along with the right leg, because Nick was complaining of severe pain in the lower portion of the leg. Dr. Shanequa determined that although Nick was pretty banged up and should not ride the dirt bike for a while, he was fine. The x-rays showed a bad sprain in the ankle area, but nothing was broken. (Hint: Keep in mind that Dr. Shanequa is Nick's primary care physician and not the ED doctor.) CPT code(s): __________

answer

Case 4—99214 Rationale: The key components support the level of service performed. Dr. Shanequa is not an emergency department physician, so he would not be billing the emergency department codes (99281-99285). The emergency department is considered outpatient.

question

CH 3 CASE STUDY 5 Megan was admitted to the hospital on May 31 at 5:00 a.m. for chest pain with nausea and heartburn. A comprehensive history was taken, and a comprehensive exam was done. Twelve hours later, after labs, x-rays, and monitoring had been completed, and with no repeat in symptoms, it was determined that Megan had suffered a bout of GERD, and she was released to go home. CPT code(s): __________

answer

Case 5—99235 Rationale: Admission and discharge were performed on the same date, May 31; so this code would be the appropriate assignment for this scenario

question

CH 3 CASE STUDY 6 Skilled Nursing Facility Discharge Summary This 83-year-old has been a resident for the past 1½ years. She was admitted because she had polio with left hemiparesis with speech impediment. She was hospitalized 4 months ago with an exacerabation of COPD, dehydration, and low blood pressure. After physical, speech, and occupational therapy, the patient has now become more independent and is able to walk behind her wheelchair. She is able to perform all of her ADLs. Routine lab work was completed last week and was found to be within normal ranges. The patient is being discharged to her daughter's home. Final examination of Patient The patient is alert. Vital signs: BP 120/66, P-64, R-12 weight -1 65 lb. HEENT: Head- normocephalic EENT: clear. NECK: No lymphadenopathy or thyromegaly. LUNGS: Clear, good air entry. HEART: Regular rhythm, no murmurs. Distal pulses palpable. ABDOMEN: Soft, nondistended. NEUROLOGICAL: Cranial nerves 2-12 grossly intact except for speech impediment. Has left hemiparesis. Discharge records were completed and instructions, and prescriptions were given to the patient's daughter. CPT code(s): ______________

answer

Case 6—99315 Rationale: The service completed was a discharge summary and because no time was recorded; the lower-level discharge summary code is selected.

question

CH 3 CASE STUDY 7 this patient has been a patient of mine for six years, and I saw him three months ago fro his annual physical. Today he presents with a cough for the last two days with a fever of 101 and is short of breath (SOB). Personal medial history is significant for appendicitis in 2003. this well nourished, well developed 25 year old patient presents with a cough and fever. BP 120/70. Height: 5 feet 9 inches. Weight: 175 lb. Ears: Auditory canals and tympanic membranes within normal limits. Oropharynx: No significant findings. Lungs: bilaterally congested heart: regular sinus rhythm abdomen: soft liver and spleen: not palpable assessment: acute bronchitis plan: patient was prescribed an antibiotic. see medication order for details. CPT codes:

answer

Case 7—99213 Rationale: The history is expanded problem focused, the examination is expanded problem focused, and the medical decision making is low complexity.

question

CH 3 CASE STUDY 8 This 93 year old was seen today in her home to reevaluate a rash that she has had for the last three weeks. Patient appears alert and responsive. BP: 130/80. Heart: normal rate and rhythm Abdomen: Soft with no masses present Skin: the rash that was previously present on the patient's left arm and shoulders is resolved. Patient was instructed to call if the rash reappears. CPT codes:___

answer

Case 8—99347 Rationale: This service was provided in the patient's residence to reevaluate a condition; therefore, it is reported with a code from the Home Service Established Patient subsection of the E/M codes. The history is problem focused, the examination is problem focused, and the medical decision making is straightforward.

question

CH 3 CASE STUDY 9 Office Note This 16 year old presents today for his annual physical. this patient has been under my care since he was 6 years old. This patient has no known medical problems. Please see previous family history taken in May of last year. There are no additional items to add to that history. SOCIAL HISTORY The patient is a junior in high school and denies use of drugs or alcohol. He is a swimmer and trains year round and is hoping to secure a college swimming scholarship. Denies any other social risk factors at this time. Patient was given patient educational materials on social risks that are relevant to his age. PHYSICAL EXAM Vital signs: as recorded by nurse. HEENT: within normal limits NECK: examination and thyroid are normal ABDOMEN: There are no masses or tenderness noted. Scar from previous appendectomy at age 12. HEART: normal sounds, no murmurs MUSCULOSKELTAL: there are no significant findings. patient has better than average muscle strength and tone. No laboratory tests or procedures were ordered. Patient is current on all immunizations. patient instructed to return in one year for physical, or sooner if an acute condition occurs. CPT code:

answer

Case 9—99394 Rationale: This service is classified as a preventative medicine service. The patient is an established patient between the ages of 12 to 17

question

CH 3 CASE STUDY 10 This 30 year old male patient presents today for his fifth counseling visit as part of the Smoking Cessation Program. Reviewed self relaxation techniques and monitoring of physical symptoms of stress that precede cravings for nicotine. Client reports reduction of three to five cigarettes per day since last visit. Patient was instructed to continue to record nicotine use and stress levels. Patient to schedule appointment in two weeks. CPT code:

answer

Case 10—99407 Rationale: This service is classified as an individual behavior change intervention. The length of the smoking cessation encounter is 35 minutes

question

What is the difference between review of systems (ROS) and physical exam (PE)?

answer

The review of systems is an inventory of body systems that is obtained FROM THE PATIENT to identify the signs and/or symptoms the patient may be experiencing or may have experienced. For example, yes I have chest pain, no I do not have abdominal pain. In a SOAP note, ROS is part of the subjective. A physical exam is performed BY THE PROVIDER (MD, NP, PA, etc.) and s/he actually touches the patient's body. In a SOAP note, PE is part of the objective

question

What is the CPT code for the highest level of care for a subsequent nursing facility visit?

answer

99310

question

T/F Beth was admitted on August 10 at 4:30 a.m. for observation for stomach cramps. She was discharged that same day at 7:30 p.m., when she began feeling better. Based on the doctor's documentation meeting the levels of service, this visit should be coded with codes in the range 99234-99236.

answer

True

question

T/F Marie presented in the ED with dehydration due to nausea and vomiting. Dr. Barnes (the hospitalist) was present when Marie came in. He took a comprehensive examination. he decided to admit Marie under his service as a 23 hour admit in observation. He ordered labs and an IV to rehydrate her. Dr Barnes should have billed a 99282-25 for his evaluation in the emergency department and then billed a 99219 for Marie's continued care in observation.

answer

False; use 99219 only

question

T/F discharge from observation status includes instructions for care, examination, and preparation of discharge records.

answer

true

question

T/F when a doctor codes an encounter by using code 99236, there needs to be at least a comprehensive history and examination and medical decision making of high complexity

answer

true

question

T/F initial observation codes 99218-99220 are used once per day, while the patient is in the hospital under observation to report the initial observation care.

answer

true

question

T/F The observation care level of 99218 includes services related to expanded history, expanded examination and problem focused medical decision making

answer

False

question

T/F There are average times associated with the observation care discharge code 99217

answer

False

question

T/F code 99235 would be reported if there is a detailed history, detailed examination and medical decision making of high complexity

answer

False

question

T/F a patient can be admitted to the hospital as a inpatient and then discharged to observation.

answer

False

question

T/F the observation care level of service reported by the supervising physician should include the services related to initiating observation status provided in other sites of service.

answer

true

question

Which of the following are parts of medical decision making?

answer

Number of possible diagnoses or management options that must be considered Amount or complexity of medical record, diagnostic tests, or other information that must be obtained, reviewed, and analyzed Risk of significant complications, morbidity, and/or mortality associated with the patient's presenting problem, the diagnostic procedures, and/or the management options Correct all of the answers

question

Per CPT guidelines, a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words, is the definition of the:

answer

chief complaint

question

Which of the following are considered components of the social history?

answer

occupational history AND marital history

question

Select the appropriate E/M code for an established patient office visit in which a comprehensive history and expanded problem-focused physical examination were performed and medical decision making was of low complexity.

answer

99213Rationale: See E/M Services Guidelines, Instructions for Selecting a Level of E/M Service, in the CPT manual. Two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M services for an established patient seen in the physician office.

question

Preventative medicine services are based on which of the following criteria?

answer

age of the patient

question

When counseling consumes more than half the total visit time, ___________ may be used as the criterion for assigning the E/M code IF it is documented. (I am looking for a one word answer here.)

answer

time

question

When the sole purpose of the telephone/Internet communication is to arrange a transfer of care or other face-to-face services, the code range 99444-99449 for interprofessional telephone/Internet consultations are not reported. However, the codes are appropriate to use if the decision to accept transfer of care cannot be made until after the initial interprofessional telephone/Internet consultation.

answer

TrueRationale: See E/M Online Medical Evaluation guidelines preceding code range 99444-99449 in the CPT manual.

question

Observation E/M codes (99218-99220) are used when:

answer

A patient is placed in designated observation status.

question

History, physical examination, and medical decision making are the __________ components considered in assigning an E/M code. (I am looking for a one word answer here.)

answer

key

question

Documentation in history of use of drugs, alcohol, and/or tobacco is considered part of the _____________________.

answer

social history

question

Per CPT guidelines, a presenting problem of moderate severity is one that:

answer

Has a moderate risk of morbidity without treatment, a moderate risk of mortality without treatment, uncertain prognosis, or increased probability of functional impairment.

question

A nursing facility patient develops an acute illness and is seen by her attending physician. He performs a detailed interval history and a detailed physical examination and performs medical decision making of moderate complexity. What code should the physician use to report these services?

answer

99309

question

Dr. Smith sees a patient in consultation in the hospital at the request of Dr. Jones. He renders an opinion. He then takes over the management of a portion of the patient's care. What codes should Dr. Smith use to bill for his subsequent hospital visits?

answer

Subsequent hospital care codes No codes; the initial consultation includes all subsequent visits.

question

Select the appropriate E/M code for a new patient office visit in which a comprehensive history and comprehensive physical examination were performed and medical decision making was of straightforward complexity.

answer

99202Rationale: See E/M Services Guidelines, Instructions for Selecting a Level of E/M Service, in the CPT manual. All of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M services for a new patient seen in the physician office.

question

Which E/M codes are used to report services to patients in a facility that provides room, board, and other personal assistance services, generally on a long-term basis?

answer

domicillary, rest home, or custodial care services

question

Which is the BEST answer about reporting the level of service of physician services E/M codes?

answer

Documentation of the history, physical examination, and medical decision making determines the level.

question

Assign the appropriate E/M code for an outpatient office consultation in which the physician performed a detailed history, a comprehensive physical examination, and medical decision making of moderate complexity.

answer

99243Rationale: See E/M Services Guidelines, Instructions for Selecting a Level of E/M Service, in the CPT manual. All of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M services for a new patient seen in the physician office for a consultation.

question

In order to report one critical care code of 99292, a physician must spend between __________ and 104 minutes with a critically ill patient.

answer

75

question

AHIMA Hospital has a "fast-track" department attached to the emergency department. This area is staffed by emergency department physicians on a rotating basis, treats minor problems, and is open from 5 am to 8 pm. What codes should be used to report services rendered in this department?

answer

Office or other outpatient services codesRationale: If the department is not open 24 hours, office or other outpatient services codes are used.See instructions preceding code 99281. The services are codeable, but the outpatient services codes must be used.

question

Pediatric in patient critical care, patient six months of age, third day. What is the correct CPT code?

answer

99472Rationale: Index Critical Care Services, pediatric, subsequent. Note that pediatric critical care is reported in units of days, unlike adult critical care, which is reported in increments of 30 minutes.

question

A physician sees a patient in his office in the morning, then again in the early afternoon, at which time he sends the patient to the hospital in observation status. Later that day he visits the patient in the hospital and admits him as a full inpatient. What E/M code(s) should be assigned for this day of care.?

answer

One code for the inpatient admission onlyRationale: All the E/M services "roll up into" the most intensive service, which is the hospital admission visit. See definitions preceding code 99201. Individual codes should not be assigned for the visits prior to the admission,although the medical decision making that occurred then would be a part of the medical decision making for the hospital admission.

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