question

brief HPI

answer

consists of one to three elements of the history of the presenting illness (HPI)

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care plan oversight

answer

a service billed once a month, which includes all care rendered to a patient over a 30-day period of time

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case management

answer

a service provided by an attending physician in which the physician not only supervises but coordinates direct care received by a patient

question

chief complaint (CC)

answer

the reason for the patient encounter

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complete PFSH

answer

review of two or all three of the past, family, and/or social history areas

question

comprehensive examination

answer

highest level of examination and consists of a multisystem examination or complete examination of a single organ system

question

comprehensive history

answer

documentation of four or more elements of the history of presenting illness (HPI), a complete review of systems (ROS), and a complete PFSH; perform all elements identified by a bullet in at least 9 organ systems or body areas and document at least 2 elements by a bullet from each of the 9 areas/systems

question

contributory components

answer

factors that contribute to the selection of E/M codes: counseling, coordination of care, and nature of the presenting problem

question

consultation

answer

services rendered by a provider when his or her opinion or expertise is requested by another provider or appropriate source; distinguish a consult by the presence of the 3 Rs; the provider receives a Request to Render an opinion and in doing do are Responding to the request.

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critical care

answer

a patient who requires constant attention by the provider due to situations related to the patient's medical condition and whose illness or injuries would put the patient at high risk should he or she not get this constant attention

question

detailed examination

answer

examination of affected area, but also other systems or related organs

question

detailed history

answer

four or more elements of the HPI, a ROS of 2-9 systems, and an element from the PFSH related to the patient's problem; at least 2 elements identified by a bullet from each of 6 areas/systems or at least 12 elements identified by a bullet in 2 or more areas/symptoms

question

elements of examination

answer

system or body area that was examined by the provider

question

Emergency Department (ED)

answer

a hospital-based facility that provides episodic services to patients who present for immediate medical attention

question

established patient

answer

a patient who has received professional services from a physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years

question

evaluation and management (E/M)

answer

section in CPT that is used to report the evaluation of a patient's condition and then the management or care plan for the condition

question

expanded problem-focused examination

answer

where the affected area is examined along with other body systems or areas that might also be affected by the problem that brought the patient to the office; at least 6 elements identified by a bullet

question

expanded problem-focused history

answer

one to three elements of the history of the present illness as well as a review of systems directly related to the chief complaint

question

extended HPI

answer

consists of at least four elements of the history of presenting illness (HPI)

question

face-to-face time

answer

used for office and other outpatient visits and consultations; the time a physician spends face-to-face with the patient and or family

question

family history

answer

information regarding immediate family members who suffer from a chronic or acute illness that would impact the care of the patient

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high-complexity medical decision-making

answer

medical decision-making of a higher or more complex level

question

history

answer

history of present illness, review of systems, and past, family, and social history make up the complete patient history

question

history of present illness (HPI)

answer

a chronological description of the patient's present illness

question

initial observation care

answer

the initial care for patients who are seen for evaluation and management services during observation

question

low birth weight (LBW)

answer

an infant with present body weight of 1,500 to 2,500 grams

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low-complexity medical decision making

answer

involves medical decision-making that is of low risk to the patient

question

moderate-complexity medical decision making

answer

higher level of elements and more complex combination of risk factors that need to be decided on

question

nature of the presenting problem

answer

the severity of the presenting problem; five types of presenting problems are present in CPT

question

new patient

answer

a patient who has not received professional services from a physician or another physician of the same specialty who belongs to the same group practice within 3 years

question

observation / observation status

answer

where the patient is in the hospital for a short time to determine the course of action

question

past, family, and/or social history (PFSH)

answer

the last portion of the history of the present illness; consists of past, family and social history of the patient

question

past history

answer

any past medical information that may impact the medical decision-making process

question

pertinent PFSH

answer

a review of the history area related to the problem identified in the HPI

question

physician standby services

answer

physician requests another physician to stand by in the event the first physician's services are needed

question

place of service (POS)

answer

a code number used to convey the place where the patient received care or service

question

preventive medicine services

answer

services provided to a patient who is presenting to a medical office for a "well visit" or a physical examination that includes a routine checkup, annual gynecological examination, or other examinations whose focus is promoting health

question

problem-focused history

answer

a brief history of present illness that is related to the problem that brought the patient to the office; 1 - 5 elements identified by a bullet

question

psychiatric residential treatment center

answer

treatment center that provides 24-hour care that includes a therapeutically planned and professionally staffed group living and learning environment with physician assessment and care plans

question

revenue

answer

the amount of money a practice will make

question

review of systems (ROS)

answer

an inventory of body systems that is obtained from the patient to identify signs and symptoms that the patient may be experiencing or has experienced

question

SOAP note

answer

provider note that contains the subjective (HPI/ROS/PFSH), objective (exam), assessment (diagnosis), and plan (medical decision making) of a patient encounter

question

social history

answer

part of the HPI that discusses the patient's marital status; use of tobacco, alcohol, drugs; and other social factors that would impact patient care

question

straightforward medical decision-making

answer

medical decision-making that is of low or straightforward risk

question

unit / floor time

answer

used for hospital observation services, inpatient hospital care, initial and follow-up hospital consultations and nursing facilities; time includes when the provider is present on the patient's unit and at the bedside rendering services

question

very low birth weight (VLBW)

answer

weight of an infant less than 1,500 grams

question

evaluation and management coding

answer

Three major questions must be asked when identifying an E/M code: 1) Is the patient new or established? 2) Where is the service provided? 3) What is the degree of the service rendered?

question

level of service

answer

Seven components go into making up levels of service for E/M codes. The first three are considered key components; the rest are considered contributory components. 1) history 2) examination 3) medical decision making 4) counseling 5) coordination of care 6) nature of presenting problem 7) time

question

level of service history

answer

Four types of history: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive

question

types of history

answer

1) chief complaint (CC) 2) history of presenting illness (HPI) 3) review of systems (ROS) 4) past, family, and social history (PFSH)

question

levels of examination

answer

• Problem Focused: 1 - 5 elements • Expanded Problem Focused: 6+ elements • Detailed: 2 elements from 6 areas/systems or 12+ from 2+ body systems • Comprehensive: all elements from 9 areas/systems and document 2 elements from each of 9 areas/systems

question

medical decision making

answer

There are 4 levels of medical decision making: • straightforward • low complexity • moderate complexity • high complexity The type of medical decision making is based on 3 factors: • The number of diagnoses or management options • The amount and/or complexity of data to be reviewed • The risk of complications and/or morbidity or mortality

question

number of diagnoses or management options

answer

The value of terms is approximate the number of diagnoses or management options: • minimal - at least 1 • limited - at least 1 • multiple - at least 2 • extensive - at least 2

question

amount and/or complexity of data to be reviewed

answer

Five, nonstandardized terms are used to describe the level of data reviewed: • none • minimal • limited • moderate • extensive

question

risk of significant complications, morbidity, and/or mortality

answer

...

question

nursing facility services

answer

Includes: skilled nursing facilities (SNF) long term care facilities (LTCF) intermediate care facilities (ICF) convalescent care rehabilitative care psychiatric residential treatment center

question

nursing facility assessments

answer

A resident assessment instrument (RAI) includes the Minimum Data Set (MDS), Resident Assessment Protocols (RAPs) and utilization guidelines.

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