Chapter 8 Short Notes Flashcards

1
Q

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

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

assignment code that explains the setting

A

place of service

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3
Q

Office visits may include…

A

routine physical examinations or problem-focused examinations of limited scope

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4
Q

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

A

consultation

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5
Q

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

A

admission

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6
Q

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

A

office visit

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7
Q

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

A

new patient

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8
Q

any patient not classified as new

A

established patient

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9
Q

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

A

outpatient

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10
Q

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

A

inpaitent

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11
Q

foundation for the level of service

A

nature of the presenting problem

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12
Q

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

A

level of service

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13
Q

key components in E/M levels are…

A

history, examination, and medical decision making

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14
Q

contributory factors in E/M levels are…

A

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

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15
Q

the nature of the presenting complaint will…

A
  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
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16
Q

four elements of a history are…

A

CC, HPI, ROS, and PFSH

17
Q

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

18
Q

Level of History: brief

A

1 to 3 elements are in the notes

19
Q

Level of History: extended

A

4 or more elements are in the notes

20
Q

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

21
Q

Problem-pertinent ROS includes

A

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

22
Q

Expanded ROS includes

A

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

23
Q

Complete ROS includes

A

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

24
Q

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

A

past history

25
set of questions relating to past and current activities common for the patient's age
social history
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
family history
27
new patients office visits include
all 3 areas of PFSH
28
established office visits include
2 of the 3 areas of PFSH
29
initial visits require
1 of the 3 areas of PFSH