Midterm: OMT Documenting and Coding

Question 1

What did the HIPPA act of 1996 state, in Layman’s terms?

Answer 1

If it isn’t written, it didnt happen

-basically made it illegal to over bill

Question 2

What is the level of coding based on?

Answer 2

1. History-requires 2 of 3 areas
2. Physical-based on number of areas
3. Medical decision making-requires 2 of 3 areas

Question 3

What is required for any sort of billing?

Answer 3

the CC

-probably why they stress it so much

Question 4

How many signs and symptoms do you need for comprehensive?

Answer 4

1-3=brief
>3=extended
>3+=comprehensive

Question 5

How many ROS do you need for each section of code, pertinent, extended and complete?

Answer 5

Pertinent=1
Extended=2-9
Complete=10+

Question 6

If you have a new patient, do you need to hit all PMH, FH, and SH to be labeled as complete?

Answer 6

Yes, only 3/3 is complete for new patient. 2/3 Complete for all else

Pertinent=1/3

Question 7

Physical exam scoring: 1-5?

Answer 7

Problem focused

Question 8

Physical exam scoring: 6+?

Answer 8

Expaned problem focused

Question 9

Physical exam scoring: 12 bullets in 6 systems?

Answer 9

Detailed

Question 10

Physical exam scoring: 2 of 9+ systems?

Answer 10

Comprehensive

Question 11

In the assessment portion of SOAP note, how do you list somatic dysfunction diagnosis?

Answer 11

List body regions: thoracic SD or cervical SD, not specific findings! (thats for Objective)

Question 12

When listing diagnoses, how specific should you be?

Answer 12

As specific as possible so any doctor could follow and pick up where you left off

So not Low back pain–> Lumbar pain
Not knee pain: osteoarthritis

Question 13

What three things are needed for medical decision making? Which one is required?

Answer 13

1. Number of Dx and Tx
2. Amount of medical data
3. Complexity of Dx and Risk

RISK IS REQUIRED

Question 14

What is considered minimal risk?

Answer 14

One self-limited or minor disease

-ie cold

Question 15

What is considered low risk?

Answer 15

2+ self-limited; one stable chronic; 1 acute uncomplicated

Question 16

What is considered moderate risk?

Answer 16

2+ stable; undiagnosed new problem with uncertain diagnosis

Question 17

What is considered high risk?

Answer 17

Eminent threat; one chronic illness with severe exacerbation

Question 18

How many body regions are there in coding?

Answer 18

10!

Head (including OA)
Cervical
Thoracic
Ribs
Abdomen
Lumbar
Sacrum
Pelvis
UE (counts as one, also SC and AC joints!)
LE (counts as one)

Question 19

So if you treat OA, C6, Left arm, right arm, left leg and pelvis, how many body regions did you treat?

Answer 19

5!

Question 20

Can you bill for a procedure and an office visit on the same day?

Answer 20

Yes, but only if the decision to do the procedure was made at the time of the visit

Question 21

Documenting an OMM procedure must include?

Answer 21

1. Consent
2. Procedure description (where and what)
3. Disposition-response to treatment
4. Follow up-after procedure