question

These elements would be part of the ? history: employment, education, use of drugs. a. past b. social c. family d. any of the above

answer

b. social

question

The level of E/M service is based on: a. documentation b. key components c. contributing factors d. all of the above

answer

d. all of the above

question

The examination is the ? portion of the E/M service. a. subjective b. objective c. assessment d. plan

answer

b. objective

question

Medical decision making (MDM) is based on the ? the physician must consider about the management of a patient's condition. a. number of diagnoses b. risk of morbidity c. amount of data d. all of the above

answer

d. all of the above

question

The Hospital Inpatient Services subsection is used for patients admitted to: a. a skilled nursing facility b. a temporary care unit c. an acute care facility d. a hospital observation unit

answer

c. an acute care facility

question

The request for advice or opinion from one physician to another physician is this type of service: a. counseling b. concurrent care c. coordination of care d. consultation

answer

d. consultation

question

Critical care codes are reported based on: a. the three key components--history, exam, MDM b. time c. amount of documentation d. procedures performed

answer

b. time

question

Codes from the E/M subsection Nursing Facilities Service are used to report services provided in nursing facilities that used to be known as: a. skilled nursing facility b. intermediate care facility c. long-term care facility d. all of the above

answer

d. all of the above

question

When a physician performs a preventive care service, the extent of the exam is determined by the: a. age b. gender c. gender and age d. length of time elapsed since last exam

answer

a. age

question

According to information in 99468, what is the age of a neonate? a. 28 days or younger b. less than 7 days c. less than 20 days d. none of the above

answer

a. 28 days or younger

question

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 obtained and extended HPI, and extended ROS, and a pertinent PFSH. What is the level of history? a. problem-focused b. expanded problem-focused c. detailed d. comprehensive

answer

c. detailed

question

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

answer

a. 99284

question

An established patient is one who has received professional service from the physician or another physician of the exact same specialty and subspecialty in the same group within the past (?) years.

answer

three

question

The term used to describe a patient who has NOT been formally admitted to a health care facility is (?)

answer

outpatient

question

A new patient presents to the physician's office at which time the physician provides a comprehensive history and exam with a high complexity MDM. CPT CODE: (?)

answer

99205

question

An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity.CPT CODE: (?)

answer

99253

question

A 40-year-old established patient presents to the physician office for a preventive care exam. CPT CODE: (?)

answer

99396

question

History and exam of the normal newborn infant born in a hospital setting. CPT CODE: (?)

answer

99460

question

A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days. A *detailed history* is then taken. She had associated fever of 101 degrees yesterday. Mom treated her with Tylenol. The fever this AM is 99 degrees. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of otitis. Brother was sick earlier this week, The physician performed a *detailed exam* of the ENT as well as a *limited exam* of GI, lungs, and heart. Vital signs were taken in the office. The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic. The *MDM* is stated to be *moderate.* CPT CODE: (?)

answer

99214

question

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. CPT CODE(S): (two codes)

answer

99291 99292

question

Complete the following blanks that refer to the three factors that the coder must consider in the assignment. 1. (?) of service 2.(?) of service 3.(?) status

answer

place of service type of service patient status

question

The code range for Home Services is (?)

answer

99341-99350

question

The four types of patient status are:

answer

1. New 2. Established 3. Outpatient 4. Inpatient

question

The (?) is a statement describing the reason for the encounter and is a history element.

answer

Chief Complaint (CC)

question

chest (HPI element?)

answer

location

question

tightness (HPI element?)

answer

quality

question

worst I've ever had (HPI element?)

answer

severity

question

since last night (HPI element?)

answer

duration

question

continuous (HPI element?)

answer

timing

question

on exertion (HPI element?)

answer

context

question

some relief with rest (HPI element?)

answer

modifying factors

question

some shortness of breath (HPI element?)

answer

associated with signs and symptoms

question

Examination type: COMPREHENSIVE

answer

The MOST EXTENSIVE examination that encompasses a complete single specialty exam or complete multisystem exam.

question

Examination type: EXPANDED PROBLEM-FOCUSED

answer

Examination limited to the affected body area or organ system AND OTHER RELATED ORGAN SYSTEMS.

question

Examination type: PROBLEM-FOCUSED

answer

Examination limited to the affected body area or organ system identified by the CHIEF COMPLAINT.

question

Examination type: DETAILED

answer

An EXTENDED EXAMINATION of the affected body areas and related organ system(s).

question

Is the NECK part of the body area (BA) or organ system (OS)?

answer

body area (BA)

question

Is the SKIN part of the body area (BA) or organ system (OS)?

answer

organ system (OS)

question

Are the EYES part of the body area (BA) or organ system (OS)?

answer

organ system (OS)

question

Is the BACK part of the body area (BA) or organ system (OS)?

answer

body area (BA)

question

Is the RESPIRATORY part of the body area (BA) or organ system (OS)?

answer

organ system (OS)

question

What are the four elements of history?

answer

1. Chief Complaint (CC) 2. History of Present Illness (HPI) 3. Review of Systems (ROS) 4. PFSH (Past, Family, Social History)

question

Complexity of medical decision making is based on what three elements?

answer

1. # of Diagnosis or Management options 2. Amount and/or complexity of Data to Review 3. Risk of complication or death if not treated

question

What are the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of service?

answer

1. History 2. Exam 3. MDM (Medical Decision Making)

question

What are the four levels of history type?

answer

1. Problem focused 2. Expanded problem focused 3. Detailed 4. Comprehensive

question

What are the four levels of medical decision making complexity?

answer

1. Straightforward 2. Low 3. Moderate 4. High

question

What are the three contributing factors?

answer

1. Counseling 2. Coordination of Care 3. Nature of Presenting Problem

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