Billing and Coding

Question 1

E/M level 1 (new)

Answer 1

History - problem focused

Physical Exam - Problem focused

MDM - straightforward

Question 2

E/M level 2 (new)

Answer 2

History - extended problem focused

Physical Exam - extended problem focused

MDM - straightforward

Question 3

E/M level 3

Answer 3

History - detailed

Physical Exam - detailed

MDM - low complexity

Question 4

E/M level 4 (new)

Answer 4

History - comprehensive

Physical Exam - comprehensive

MDM - moderate complexity

Question 5

E/M level 5 (new)

Answer 5

History - comprehensive

Physical Exam - comprehensive

MDM - high complexity

Question 6

Straightforward MDM complexity

Answer 6

Problem points: 1

Data points: 1

Risk: minimal

Question 7

Low MDM complexity

Answer 7

Problem points: 2

Data points: 2

Risk: low

Question 8

Moderate MDM complexity

Answer 8

Problem points: 3

Data points: 3

Risk: moderate

Question 9

High MDM complexity

Answer 9

Problem points: 4

Data points: 4

Risk: high

Question 10

Minimal risk

Answer 10

one self-limited or minor problem

Question 11

Low risk

Answer 11

2+ self-limited or minor problems

1 stable chronic illness

acute uncomplicated illness or injury

ex: ankle sprain, UTI, rhinitis

Question 12

Moderate risk

Answer 12

1+ chronic illnesses with mild exacerbation or progression

2+ stable chronic illnesses

Prescription drug management

undiagnosed new problem with uncertain prognosis

acute illness with systemic symptoms

acute complicated injury

Question 13

High risk

Answer 13

1+ chronic illnesses with severe exacerbation or progression

acute or chronic illness or injury that pose threat to life or bodily function

Question 14

2 data points

Answer 14

for independent review of an image, tracing, or specimen.

review and summation of old records.

Question 15

data points for both ordering and independently reviewing an image or ECG

Answer 15

2

Question 16

1 data point

Answer 16

review/order lab test.

review/order radiology.

review/order medicine test.

discuss test with performing physician.

decision to obtain old records.

Question 17

1 problem point

Answer 17

self-limited or minor

stable established problem

Question 18

2 problem points

Answer 18

worsening established problem

Question 19

3 problem points

Answer 19

new problem with no additional workup planned

Question 20

4 problem points

Answer 20

new problem with additional workup planned

Question 21

Problem focused physical exam

Answer 21

1-5 bullets/findings

1+ organ systems

Question 22

EPF physical exam

Answer 22

6+ bullets/findings

1+ organ systems

Question 23

Detailed PEx

Answer 23

12+ bullets/findings

2+ bullets in 6+ systems

Question 24

Comprehensive PEx

Answer 24

18+ bullets

2+ bullets in 9+ systems

Question 25

Problem focused Hx

Answer 25

HPI: 1-3 elements

ROS: none

PFSH: none

Question 26

Extended problem focused Hx

Answer 26

HPI: 1-3 elements

ROS: 1 system

PFSH: none

Question 27

Detailed Hx

Answer 27

HPI: 4+ elements or chronic conditions

ROS: 2-9 systems

PFSH: 1/3 pertinent PFSH

Question 28

Comprehensive Hx

Answer 28

HPI: 4+ elements or 3 chronic conditions

ROS: 10+ systems

PFSH: 3/3 complete PFSH

Question 29

How many components are required for a new patient to meet a level of care?

Answer 29

3/3

History, PEx, and MDM all have to be a certain level or higher.

Question 30

How many components are required for an established patient to meet a level of care?

Answer 30

2/3

2/3 components have to be a certain level or higher.

Question 31

CPT codes

Answer 31

992_ _

992 (0 for new, 1 for estab) (E/M level 1-5)

Question 32

Clinical E/M levels

Answer 32

based on time spent coordinating care.

must record duration of encounter

document in detail the counseling and coordination of care that occurred