Documenting and coding

Question 1

Codes used for billing patient encounters

Answer 1

common procedure terminology codes

Question 2

code for office visit

Answer 2

99213, 99214

Question 3

code for OMT to 5 or 6 body regions

Answer 3

98927

Question 4

H.R.3103

Answer 4

Health Insurance Portability and Accountability Act of 1996; transition to EMR, electronic financial chart audits

Question 5

code decision is based on what key elements

Answer 5

history, PE, medical decision making, or time

Question 6

How is history taking scored?

Answer 6

requires 2 of 3 areas to meet or exceed overall complexity

Question 7

How is PE scored?

Answer 7

quantity of examinations

Question 8

How is decision making scored?

Answer 8

requires 2 of 3 areas to meet or exceed complexity

Question 9

Complexity levels of history taking

Answer 9

focused, problem focused, expanded problem focused, detailed, comprehensive

Question 10

Problem pertinent code

Answer 10

99213

Question 11

Extended problem code

Answer 11

99214

Question 12

Complete problem code (10+ ROS)

Answer 12

99215

Question 13

Problem focused PE

Answer 13

1-5 elements

Question 14

Expanded problem focused PE

Answer 14

6+ elements

Question 15

How to document OSE in objective note?

Answer 15

OSE: T5-7 N RR SL

Question 16

Three components of medical decision making complexity

Answer 16

number of dx and tx, amount of medical data reviewed, complexity of dx and risk level

Question 17

Documenting SD in assessment note?

Answer 17

“Somatic dysfunction of _____ region(s)”

Question 18

What must be document in a SOAP note for OMT?

Answer 18

patient consent obtained!

Question 19

Four main parts of OMT procedure note

Answer 19

consent, procedure description, disposition, follow up plan