Ch 11: Content Review

Question 1

What are the three contributing factors?

Answer 1

• Counseling
• Coodination of Care
• Nature of Presenting Problem

Question 2

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

Answer 2

Outpatient

Question 3

Codes from the E/M subsection Nursing Facilities Service are used to report services provided in nursing facilities that used to be known as:

Answer 3

All of the above

Question 4

The HPI must be documented in the medical record by:

Answer 4

The physician

Question 5

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

Answer 5

• History
• Examination
• Medical Decision Making

Question 6

According to E/M guidelines, a(n) _____ exam encompasses a complete single-specialty exam or complete multisystem exam.

Answer 6

Comprehensive

Question 7

The request for advice or opinion from one physician to another physician is this type of service:

Answer 7

Consultation

Question 8

The code range for Home Services is ______.

Answer 8

99341-99350

Question 9

These elements would be part of the ______ history: employment, education, use of drugs.

Answer 9

Social

Question 10

The definition of low birth weight can be found in the notes for subheading ______.

Answer 10

Initial and Continuing Intensive Care Services

Question 11

The level of E/M service is based on:

Answer 11

All of the above

Question 12

What are the four elements of history?

Answer 12

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past, Family, and/or Social History (PFSH)

Question 13

The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?

Answer 13

Moderate

Question 14

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

Answer 14

• Number of diagnoses or management options
• Amount and/or complexity of data to review
• Risk of complications or death if the condition is left untreated

Question 15

When a physician performs a preventive care service, the extent of the exam is determined by the:

Answer 15

Age

Question 16

Bruising would be an element of review of this organ system.

Answer 16

Hematologic

Question 17

The Hospital Inpatient Services subsection is used for patients admitted to:

Answer 17

An acute care facility

Question 18

What are the four levels of medical decision making complexity?

Answer 18

• Straightforward
• Low-complexity
• Moderate-complexity
• High-complexity

Question 19

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 obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history?

Answer 19

Detailed

Question 20

Medical decision making (MDM) is based on the ____ the physician must consider about the management of a patient’s condition.

Answer 20

All of the above

Question 21

The _____ is a statement describing the reason for the encounter and is a history element.

Answer 21

Chief Complaint (CC)

Question 22

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 22

3

Question 23

The examination is the _____ portion of the E/M service.

Answer 23

Objective

Question 24

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward. What is the CPT code?

Answer 24

99341

Question 25

What are the four levels of history type?

Answer 25

• Problem focused
• Expanded problem focused
• Detailed
• Comprehensive

Question 26

The four types of patient status are:

Answer 26

• Outpatient
• Inpatient
• New
• Established

Question 27

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?

Answer 27

Detailed

Question 28

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?

Answer 28

99284

Question 29

According to information in 99486, what is the age of a neonate?

Answer 29

28 days or younger

Question 30

Critical care codes are reported based on:

Answer 30

Time