Ch 11: Pretest Flashcards
Evaluation and Management
Only information documented in the ______ ______ may be considered in determining level of service.
Patient Record
The key components of history, examination, and medical decision making enable the coder to choose the appropriate ______ ______ ______.
Level of Care
Only the ______ ______ may bill for hospital discharge services.
Attending Physician
The ______ ______ is the subjective portion of the E/M service.
Patient History
While any office staff member may be involved in taking the patient history, the documentation is found in the patient’s medical record and is recorded by the ______.
Physician
Very low birth weight (VLBW) is defined as birth weight below ______.
1500 grams
The MDM is based on what?
Complexity of the medical decision
A patient who has been treated within the past 3 years by the physician or a member of his/her practice who has the same specialty is considered what type of patient?
Established Patient
Counseling, coordination of care, nature of presenting problem, and time are considered what?
Contributory Factors
What examination level is focused on the body area or organ system identified by the patient’s chief complaint?
Problem Focused
What key components enable the coder to chose the appropriate level of care?
- History
- Examination
- Medical Decision Making (MDM)
Patient history is the ______ portion of the E/M service.
Subjective
Anything under 1500 grams is considered ______ for a newborn.
Very Low Birth Weight (VLBW)
Complexity of the medical decision is the basis for what?
Medical Decision Making (MDM)
What are the qualifications for an established patient?
A patient who has been treated within the past 3 years by the physician or a member of his/her practice who has the same specialty
