Bucks Ch 11 E/M services

Question 1

Which Appendix lists all the modifiers that are used to alter or modify codes in the CPT manual?

Answer 1

Appendix A

Question 2

What are the the 6 sections of the CPT manual

Answer 2

■ Evaluation and Management 99202-99499
■ Anesthesia 00100-01999
■ Surgery 10004-69990
■ Radiology 70010-79999
■ Pathology and Laboratory 80047-89398, 0001U-0419U
■ Medicine 90281-99607

Question 3

After the section what are the additionl divisions of categerys from genral to the most specific?

Answer 3

Section. At the top of the page, the word “Surgery” indicates the section.
Subsection. Also at the top of the page, the phrase “Integumentary System” indicates the subsection.
Subheading. The words “Skin, Subcutaneous and Accessory Structures” indicates the subheading.
Category. The words “Incision and Drainage” indicates the category.

Question 4

Unlisted service or procedure codes end in what numbers?

Answer 4

99

ex.33999

Question 5

Code assignment in the E/M section varies according to what three factors?

Answer 5

1. Place of service
2. Type of service
3. Patient status

Question 6

What are examples of place of service?

Answer 6

A physician’s office, hospital, emergency department, nursing home, and so on.

Question 7

What is the 2nd factor for code assignment in the E/M section of the CPT manual?

Answer 7

Type of Service

Question 8

4 examples of types of service are:

Answer 8

■ Consultation is a written or verbal request from one provider/physician to another to obtain an opinion and/or advice about a diagnosis or management options.
■ Admission is attention to an acute illness or injury that results in admission to a hospital.
■ Newborn care is the evaluation and determination of care management of a newly born infant.
■ **Office visit **is a face-to-face encounter between a physician and a patient to allow for primary management of the patient’s health care status.

Question 9

What is the 3rd factor for code assignment in the E/M section of the CPT manual?

Answer 9

Patient Status

Question 10

What are the four types of patient status for assignment of code in the E/M section of the CPT manual?

Answer 10

■ New patient is one who has not received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years.
■ Established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years.
■ Outpatient is one who has not been formally admitted to a health care facility or a patient admitted for observation.
■ Inpatient is one who has been formally admitted to a health care facility.

Question 11

The elements of ____ ____ ____ focus on the elements that affect the management of a patient’s condition that include:
1. number and complexity of problems addressed
1. amount and/or complexity of data reviewed
1. risk of complications and/or morbidity or mortality of patient management.

Answer 11

Medical decision making (MDM)

Question 12

To qualify, for a Medical decision making (MDM) status how many elements must be met or exceeded?

Answer 12

two of the three elements of MDM must be met or exceeded.

Question 13

____ may be used to report office or other outpatient services instead of MDM

Answer 13

Time

Question 14

What does the following information represent?

1. Number of diagnoses. The options can be minimal, low, moderate, or high.
2. Amount and/or complexity of data to review. The data can be minimal or none, limited, moderate, or extensive.
3. Risk of complication or death if the condition goes untreated. Risk can be minimal, low, moderate, or high.

Answer 14

3 elements of MDM or Medical Decision Making

Question 15

Explain the 4 complexity levels for Medical decision making
■ Straightforward
■ Low
■ Moderate
■ High

Answer 15

Straightforward decision making: Minimal diagnosis and management options, minimal or none for the amount and complexity of data to be reviewed, and minimal risk to the patient of complications or death if untreated.
Low-complexity decision making: Limited number of diagnoses and management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.
**Moderate-complexity decision making: **Multiple diagnoses and management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.
High-complexity decision making: Extensive diagnoses and management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.

Question 16

T or F
E/M guidelines are for services that require a face-to-face encounter with the patient and/or family/caregiver.

Answer 16

True

Question 17

What is the time limit to qualify as a new or established patient

Answer 17

3 years

Question 18

Are you a new patient if you go to another doctor in the same practice with the same specialty but different subspecialties

Answer 18

Yes, you have to see the same specialty and subspecialty to be considered a new or established patient.

Question 19

is it considered the same specialty and subspecialty:
Where a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, and a patient meetds with advanced practice nurses and physician assistants instead of their doctor?

Answer 19

Yes

Question 20

A ____ ____ member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service.

Answer 20

clinical staff

Question 21

A ________________ is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service.

Answer 21

“physician or other qualified health care professional”
physician or other QHP

Question 22

Selecting the appropriate level of E/M services is based on what 2 things?

Answer 22

1. The level of the MDM as defined for each service, or
2. The total time for E/M services performed on the date of the encounter.

Question 23

When evaluating a problem-

Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented __does/or does not__qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

Answer 23

does not

Question 24

A ________is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.

Answer 24

Problem

Question 25

# **straightforward** minimal MDM **problem** elements (level 2) A ________problem may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision. ____-____ or ________problem is a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

Answer 25

Minimal problem Self-limited or minor problem

Question 26

# Low/Moderate/High MDM **Problem** depending on quantity and catagory ____,____ ____ A problem with an expected `duration` of `at least one year or until the death` of the patient. For the purpose of defining `chronicity`, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). "`Stable`" for the purposes of categorizing MDM `is defined by the specific treatment goals `for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.

Answer 26

Stable, Chronic illness

Question 27

# Low/Moderate/High MDM **Problem** depending on quantity and catagory ____, ____ ____ or ____ is a `recent or new short-term problem` with `low risk of morbidity` for which treatment is considered. There is `little to no risk of mortality with treatment,` and f`ull recovery without functional impairment is expected`. *A problem that is normally self-limited or minor but is `not resolving `consistent `with` a definite and `prescribed course` is an acute, uncomplicated illness. *

Answer 27

Acute, uncomplicated illness or injury

Question 28

# Low/Moderate/High MDM **Problem** depending on quantity and catagory ____, ____ ____ is a problem` that is `new or recent` for which `treatment` has been `initiated`. The `patient is improved` and, while` `resolution may not be complete, is stable` with respect to this condition.

Answer 28

Stable, acute illness

Question 29

# **Low** MDM **Problem** (level3) `Acute, uncomplicated illness or injury` requiring ____ ____ or ____ ____ ____ A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and` full recovery without functional impairment is expected.` The `treatment required` is delivered in a `hospital inpatient `or `observation level` setting.

Answer 29

hospital inpatient or observation level care

Question 30

# Moderate/High MDM **Problem** depending on quantity and catagory ____ ____ with exacerbation, progression, or ____ ____ of ____: A `chronic illness `that is `acutely worsening,` `poorly controlled`, or `progressing with an intent to control progression` and *requiring additional supportive care or requiring attention to treatment for side effects.*

Answer 30

Chronic illness with exacerbation, progression, or side effects of treatment

Question 31

# level 4 `Moderate` MDM `Problem` ____ new problem with ____ prognosis: A problem in the differential diagnosis (most likely cause of sypmtoms) that represents a `condition likely to result in a high risk of morbidity without treatment`.

Answer 31

Undiagnosed new problem with uncertain prognosis

Question 32

# level 4 **Moderate** MDM **Problem** ____ illness with ____ symptoms: An `illness` that causes `systemic symptoms` and has a `high risk of morbidity without treatment`. Systemic symptoms may not be general but may be single system.

Answer 32

Acute illness with systemic symptoms

Question 33

# **High** level 5 MDM **problem** Chronic illness with ____ ____, progression, or ____ ____ of ____: The `severe exacerbation` or `progression` of a chronic illness or severe `side effects` of `treatment` that have `significant risk of morbidity` and `may` require `escalation` in `level of care.`

Answer 33

Chronic illness with sever exacerbation, progression, or side effects of treatment.

Question 33

# level 4 **moderate** MDM **problem** ____, ____ injury: An `injury` which `requires treatment` that `includes evaluation` of `body systems` that are n`ot directly part of the injured organ`, the `injury is extensive`, or the `treatment` options are multiple `and/or` associated `with risk of morbidity.`

Answer 33

Acute, complicated injury

Question 34

# **High** level 5 MDM **problem** Acute or chronic illness or injury that poses a ____ to ____ or ____ function An `acute illness` with `systemic symptoms`, an `acute complicated injury`, or a `chronic illness` or `injury` `with exacerbation` and/or progression or side effects of treatment, that `poses a threat to life or bodily function` in the near term `without treatment`.

Answer 34

Acute or chronic illness or injury that poses a threat to life or bodily function

Question 35

# **MDM** amount and complexity of **data** to be reviewed and analyzed Elements of analyzed and reviewd data used in the thought processes for diagnosis, evaluation, or treatment.

Answer 35

review notes from previous or external drs, independant historian, tests/labs, discussion

Question 36

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ data requires `2 points` of: Review of external note(s) (1 pt per unique source) Review of test results (1 pt per unique test) Ordering tests (1 pt per unique test) `or` Assessment requiring a independent historian

Answer 36

Limited Data

Question 37

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ data requires `3 points` of: Review of external note(s) (1 pt per unique source) Review of test results (1 pt per unique test) Ordering tests (1 pt per unique test) Assessment requiring a independent historian or Independent interpretation of test performed by another or Discussion of management or test interpretation with another.

Answer 37

Moderate Data

Question 38

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ data requires `3 points`and `2 sections `of: Review of external note(s) (1 pt per unique source) Review of test results (1 pt per unique test) Ordering tests (1 pt per unique test) Assessment requiring a independent historian and/or Independent interpretation of test performed by another and/or Discussion of management or test interpretation with another.

Answer 38

Extensive data

Question 39

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ are `imaging, laboratory, psychometric, or physiologic data`. A clinical laboratory `panel` (eg, basic metabolic panel [80047]) `is a single test`. The differentiation between single or multiple tests is defined in accordance with the CPT code set. For the purpose of data reviewed and analyzed, pulse oximetry is not a test.

Answer 39

Tests

Question 40

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ ____ is a collection of measurements that track a person's physical and mental state through biosensers. It can include measurements of heart rate, breathing, skin temperature, and brain activity

Answer 40

Physiological data

Question 41

# **MDM** amount and complexity of **data** to be reviewed and analyzed A ____ ____ is when `multiple results` of the `same unique test` (eg, `serial` blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A `unique source` is a `physician` or other qualified health care professional `in a distinct group or different specialty or subspecialty`, or a unique entity. `Review of all materials from any unique source counts as one element toward MDM.`

Answer 41

unique test

Question 42

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ `requires` an `interactive exchange`. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). `Sending chart notes or written exchanges that are within progress notes does not qualify` as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it `must be initiated and completed within a short time period (eg, within a day or two).`

Answer 42

Discussion

Question 43

# **MDM** amount and complexity of **data** to be reviewed and analyzed An `individual` (eg, parent, guardian, surrogate, spouse, witness) `who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history` (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It `does not include translation services.` The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

Answer 43

Independent historian(s)

Question 44

# **MDM** amount and complexity of **data** to be reviewed and analyzed ____ ____ an appropriate source includes `professionals` who are `not health care professionals `but may be `involved` in the `management of the patient `(eg, lawyer, parole officer, case manager, teacher). It does `not` include discussion with `family` or `informal caregivers`.

Answer 44

Appropriate source:

Question 45

# **MDM** **Risk** of Complications Morbidity or Mortality of Patient Mana ____ A state of illness or functional impairment that is `expected` to be of `substantial duration during which function is limited, quality of life is impaired, or there is organ damage` that may not be transient despite treatment.

Answer 45

Morbitity

Question 46

# **MDM** **Risk** of Complications Morbidity or Mortality of Patient Mana Examples of ____ Risk * Rest * Elastic bandages * Superficial dressings

Answer 46

Minimal

Question 47

# **MDM** **Risk** of Complications Morbidity or Mortality of Patient Mana Examples of ____Risk * OTC drugs without mention of complications * Minor surgery w/o identified risk factors * PT/OT Therapy * IV fluids w/o additives

Answer 47

Low

Question 48

# **MDM** **Risk** of Complications Morbidity or Mortality of Patient Mana Examples of ____ Risk * Prescription drug management * Secision regarding minor surgery with identified patient or procedure risk factors * Decision regarding elective major surgery without identified patient or procedure risk factors

Answer 48

Moderate