Documenting and Coding

Question 1

What is the name of the system of codes used for billing clinical encounters with patients?

Answer 1

Common Procedure Terminology (CPT)

Question 2

What codes are used for patient evaluation and disease management?

Answer 2

E and M codes

-these vary based on location (hospital v. clinic)

Question 3

Which Act required a transition to electronic medical records and allowed electronic financial chart audits?

Answer 3

HIPAA of 1996

Question 4

True or False: in selection of E and M codes, the more physical and mental work performed by the physician, the higher the level of complexity code selected

Answer 4

True; it’s based on the complexity of: history, physical exam, and medical decision making

Question 5

Which aspect of a physician visit does Medicare place the highest priority on?

Answer 5

Medical Decision Making

Question 6

True or False: a Chief Complaint (CC) in the History/Subjective section is required for any billing

Answer 6

True

Question 7

For components of the HPI (location, quality, severity, duration, timing, etc.), what levels dictate the complexity of the History for coding purposes?

Answer 7

1-3 = brief
> 3 = extended
>3 with other elements = comprehensive

Question 8

For completing a ROS (CV, ENT, Eyes, GI, GU, MSK, Neuro, Psych, Resp, etc.), what levels dictate the complexity for coding purposes?

Answer 8

1 = problem pertinent
2-9 = extended
10+ = complete

Question 9

For completing the Past Histories section of the HPI (PMH, Family Hx, Social Hx), what levels dictate the complexity for coding purposes?

Answer 9

1 = pertinent
2 = complete
3 = complete (new pt., hospital, or consult > level 3)

Question 10

For the scoring of the physical exam complexity, what are the levels?

Answer 10

Problem-Focused = 1-5 elements
Expanded Problem-Focused = 6+ elements
Detailed = 2 bullets in each of 6 systems (12+ bullets)
Comprehensive = 2 bullets in 9 systems (complete PE)

Question 11

From what source do the medical diagnoses come, and who maintains/publishes it?

Answer 11

ICD-10 by the WHO

Question 12

What is a good “rule” to keep in mind in regards to Medicare?

Answer 12

• Be as specific as possible.
• Only list Sx when the cause is unknown.

-You can list symptoms in addition to a SD if it’s unclear whether or not the SD is their cause, and no other diagnosis is known.

Question 13

For a somatic dysfunction, according to the ICD-10, how should you list them?

Answer 13

-by body region only, NOT individual findings

Question 14

What are the levels in Medical Decision Making?

Answer 14

Straight-Forward
Low Complexity
Moderate Complexity
High Complexity

Question 15

What three components go into determining the complexity level for Medical Decision Making and which component is the driving determinant for the level of service?

Answer 15

• number of diagnoses and treatments
• amount of medical data reviewed
• complexity of diagnosis and its RISK level

-Risk determines level of service; MUST be included

Question 16

What are the levels of diagnosis and risk?

Answer 16

self-limited = 1 point
established diagnosis = 1 point (if stable or improved)
established diagnosis = 2 points (if worsening)
new problem w/o further eval = 3 points
new problem w/ further eval = 4 points

Question 17

What are the levels of medical data review?

Answer 17

review or order lab, x-ray, etc. = 1 point
discuss results w/ pt. = 1 point
decision to review old records or visits = 1 point
independent review of UA, ECG, etc. = 2 points

Question 18

What are examples of the minimal risk level?

Answer 18

–one self-limited minor condition (ex: cold, insect bite)

• mgmt may require some testing (CXR, UA)
• mgmt w/ rest, OTC’s, bandages

Question 19

What are examples of the low risk level?

Answer 19

–2+ self-limited, 1 stable chronic, or 1 acute uncomplicated condition (ex: controlled HTN)

-mgmt may include OTC, minor surgery, PT, IV saline

Question 20

What are examples of the moderate risk level?

Answer 20

• chronic illness w/ exacerbation, or 2+ stable condition
• medication side effects
• acute condition w/ systemic symptoms
• complicated injury (e.g. head injury w/ concussion)
• undiagnosed new problem w/ uncertain prognosis

Question 21

What are examples of the high risk level?

Answer 21

-illness/event that poses eminent threat to life
(MI, PE, resp distress, change in neuro status)

-1+ chronic illness w/severe exacerbation

Question 22

Of the three visit portions (History, Physical Exam, and Medical Decision Making), how many must score at or above a certain complexity level (1-5) for that complexity level to be assigned to the visit?

Answer 22

2 out of the 3

Question 23

For diagnosis of a somatic dysfunction, how many of the TART findings (tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities) are required?

Answer 23

only 1

Question 24

How do you document the physical findings of a somatic dysfunction?

Answer 24

In the objective section, describing the individual elements:

• right ASIS tender, right ASIS superior, etc.
• positive Adson’s Maneuver on the right

Question 25

What body region is the OA in?

Answer 25

head

Question 26

What body region is the collarbone and scapula in?

Answer 26

upper extremity

Question 27

How are OMT services billed?

Answer 27

by number of regions

1-2, 3-4, 5-6, 7-8, 9-10

Question 28

True or False: billing both a procedure and an office visit on the same day will result in automatic denial for the office visit portion

Answer 28

True, unless the decision to perform the procedure was made at the time of the encounter. Then you can bill for both.

Ex: “Decision made to offer trial OMT to listed SD.”

Question 29

What four main components must be be contained within an OMT procedure note?

Answer 29

• -consent (benefits, risks, side effects, alternatives)
• -procedure description (body region and technique)
• -disposition (response to Tx including complications)
• -follow-up plan (post-procedure care)