Chapter 8 Short Notes

Question 1

Assignment codes from the E/M section is determined by three factors

Answer 1

1. place of service
2. type of service
3. patient statue

Question 2

assignment code that explains the setting

Answer 2

place of service

Question 3

Office visits may include…

Answer 3

routine physical examinations or problem-focused examinations of limited scope

Question 4

a request to obtain an opinion or advice about a diagnosis or management option from another physician or other appropriate source

Answer 4

consultation

Question 5

attention to an acute illness or injury that results in admission to a hospital

Answer 5

admission

Question 6

face-to-face encounter between a physician and a patient that allows for primary management of the patient’s health

Answer 6

office visit

Question 7

patient who has not received professional health service in the past three years

Answer 7

new patient

Question 8

any patient not classified as new

Answer 8

established patient

Question 9

patients that have not been formally admitted to a health care facility

Answer 9

outpatient

Question 10

patients who have been formally admitted to a healthcare facility including a hospital or nursing facility

Answer 10

inpaitent

Question 11

foundation for the level of service

Answer 11

nature of the presenting problem

Question 12

main consideration when determining reimbursement for E/M services and procedures

Answer 12

level of service

Question 13

key components in E/M levels are…

Answer 13

history, examination, and medical decision making

Question 14

contributory factors in E/M levels are…

Answer 14

counseling, coordination of care, nature of the presenting complaint, and time

Question 15

the nature of the presenting complaint will…

Answer 15

1. determine the need for counseling and coordination of care and whether time is a factor to be considered
2. influence the extent of history, examination, and decision making required

Question 16

four elements of a history are…

Answer 16

CC, HPI, ROS, and PFSH

Question 17

chronological description of how the patient’s present illness developed from the first sign and/or symptom or from the previous encounter to the present

Answer 17

HPI

Question 18

Level of History: brief

Answer 18

1 to 3 elements are in the notes

Question 19

Level of History: extended

Answer 19

4 or more elements are in the notes

Question 20

thorough inventory of anatomical body systems obtained through a series of questions designed to identify signs and symptoms the patient may be experiencing

Answer 20

ROS

Question 21

Problem-pertinent ROS includes

Answer 21

the patient’s responses for the symptoms related only to the problem

Question 22

Expanded ROS includes

Answer 22

the patient’s responses for 2 to 9 of the systems

Question 23

Complete ROS includes

Answer 23

the system(s) noted in the HPI and all additional body systems; at least 10 of the 14 systems must be reviewed

Question 24

patients illnesses, operations, hospitalizations, injuries, allergies, current medications, immunizations, and dietary status

Answer 24

past history

Question 25

set of questions relating to past and current activities common for the patient’s age

Answer 25

social history

Question 26

includes the medical events in the patient’s family including diseases that may be hereditary, could put the patient at risk, or are relevant to the patient’s chief complaint

Answer 26

family history

Question 27

new patients office visits include

Answer 27

all 3 areas of PFSH

Question 28

established office visits include

Answer 28

2 of the 3 areas of PFSH

Question 29

initial visits require

Answer 29

1 of the 3 areas of PFSH