Ch 11: Chapter Review

Question 1

Office, hospital, emergency department, and nursing home locations describe what factor in code assignments?

Answer 1

Place of service

Question 2

What patient status is assigned to an encounter that has been seen by the same specialty within the past 3 years?

Answer 2

Established

Question 3

What status is assigned to a patient who has been formally admitted to a health care facility?

Answer 3

Inpatient

Question 4

The levels of service are based on key components and what factors?

Answer 4

Contributory

Question 5

Documented key components include history, examination, and ______.

Answer 5

Medical decision making (MDM)

Question 6

Subjective information given by the patient is part of what key component?

Answer 6

History

Question 7

Documented observation by the physician about the patient’s complaint or problem is considered what type of information?

Answer 7

Objective

Question 8

Two of the three elements must be met or exceeded to qualify for a level of ______.

Answer 8

Medical decision making (MDM)

Question 9

When a physician arranges for other services to be provided to the patient, this is considered what type of contributory factor?

Answer 9

Coordination of care

Question 10

What CPT code reports services provided in an office for which the physician may not be present?

Answer 10

99211

Question 11

The last subsection in the E/M section describing an unlisted code is what type of evaluation and management service?

Answer 11

Other

Question 12

CMS developed a set of standards for documentation of E/M services which are called ______.

Answer 12

Documentation guidelines (DGs)

Question 13

A general multi-system exam that includes one to five elements identified by a bullet in one or more organ systems or body areas according to the 1995 documentation guidelines is a(n) ______?

Answer 13

Problem focused

Question 14

This term means: A discussion with a patient and/or family

Answer 14

Counseling

Question 15

This term means: A service rendered by a physician whose opinion or advice is requested by another physician

Answer 15

Consultation

Question 16

This term means: Counseling, coordination of care, nature of presenting problem, and time

Answer 16

Contributory factors

Question 17

This term means: A patient who has not received professional services from a physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years

Answer 17

New patient

Question 18

This term means: Evaluation and determination of care management of a newly born infant

Answer 18

Newborn care