Medical Coding II (Chapter 11/TEST REVIEW)

Medical Coding II (Chapter 11/TEST REVIEW)

These elements would be part of the ? history:
employment, education, use of drugs.
a. past
b. social
c. family
d. any of the above
b. social
The level of E/M service is based on:
a. documentation
b. key components
c. contributing factors
d. all of the above
d. all of the above
The examination is the ? portion of the E/M service.
a. subjective
b. objective
c. assessment
d. plan
b. objective
Medical decision making (MDM) is based on the ? the physician must consider about the management of a patient’s condition.
a. number of diagnoses
b. risk of morbidity
c. amount of data
d. all of the above
d. all of the above
The Hospital Inpatient Services subsection is used for patients admitted to:
a. a skilled nursing facility
b. a temporary care unit
c. an acute care facility
d. a hospital observation unit
c. an acute care facility
The request for advice or opinion from one physician to another physician is this type of service:
a. counseling
b. concurrent care
c. coordination of care
d. consultation
d. consultation
Critical care codes are reported based on:
a. the three key components–history, exam, MDM
b. time
c. amount of documentation
d. procedures performed
b. time
Codes from the E/M subsection Nursing Facilities Service are used to report services provided in nursing facilities that used to be known as:
a. skilled nursing facility
b. intermediate care facility
c. long-term care facility
d. all of the above
d. all of the above
When a physician performs a preventive care service, the extent of the exam is determined by the:
a. age
b. gender
c. gender and age
d. length of time elapsed since last exam
a. age
According to information in 99468, what is the age of a neonate?
a. 28 days or younger
b. less than 7 days
c. less than 20 days
d. none of the above
a. 28 days or younger
Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. the physician obtained and extended HPI, and extended ROS, and a pertinent PFSH. What is the level of history?
a. problem-focused
b. expanded problem-focused
c. detailed
d. comprehensive
c. detailed
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?
a. 99284
b. 99291
c. 99283
d. 99220
a. 99284
An established patient is one who has received professional service from the physician or another physician of the exact same specialty and subspecialty in the same group within the past (?) years.
three
The term used to describe a patient who has NOT been formally admitted to a health care facility is (?)
outpatient
A new patient presents to the physician’s office at which time the physician provides a comprehensive history and exam with a high complexity MDM. CPT CODE: (?)
99205
An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity.CPT CODE: (?)
99253
A 40-year-old established patient presents to the physician office for a preventive care exam. CPT CODE: (?)
99396
History and exam of the normal newborn infant born in a hospital setting. CPT CODE: (?)
99460
A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days. A *detailed history* is then taken. She had associated fever of 101 degrees yesterday. Mom treated her with Tylenol. The fever this AM is 99 degrees. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of otitis. Brother was sick earlier this week, The physician performed a *detailed exam* of the ENT as well as a *limited exam* of GI, lungs, and heart. Vital signs were taken in the office. The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic. The *MDM* is stated to be *moderate.* CPT CODE: (?)
99214
Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the intensive care unit with acute respiratory distress syndrome.
CPT CODE(S): (two codes)
99291
99292
Complete the following blanks that refer to the three factors that the coder must consider in the assignment.
1. (?) of service
2.(?) of service
3.(?) status
place of service
type of service
patient status
The code range for Home Services is (?)
99341-99350
The four types of patient status are:
1. New
2. Established
3. Outpatient
4. Inpatient
The (?) is a statement describing the reason for the encounter and is a history element.
Chief Complaint (CC)
chest (HPI element?)
location
tightness (HPI element?)
quality
worst I’ve ever had (HPI element?)
severity
since last night (HPI element?)
duration
continuous (HPI element?)
timing
on exertion (HPI element?)
context
some relief with rest (HPI element?)
modifying factors
some shortness of breath (HPI element?)
associated with signs and symptoms
Examination type: COMPREHENSIVE
The MOST EXTENSIVE examination that encompasses a complete single specialty exam or complete multisystem exam.
Examination type: EXPANDED PROBLEM-FOCUSED
Examination limited to the affected body area or organ system AND OTHER RELATED ORGAN SYSTEMS.
Examination type: PROBLEM-FOCUSED
Examination limited to the affected body area or organ system identified by the CHIEF COMPLAINT.
Examination type: DETAILED
An EXTENDED EXAMINATION of the affected body areas and related organ system(s).
Is the NECK part of the body area (BA) or organ system (OS)?
body area (BA)
Is the SKIN part of the body area (BA) or organ system (OS)?
organ system (OS)
Are the EYES part of the body area (BA) or organ system (OS)?
organ system (OS)
Is the BACK part of the body area (BA) or organ system (OS)?
body area (BA)
Is the RESPIRATORY part of the body area (BA) or organ system (OS)?
organ system (OS)
What are the four elements of history?
1. Chief Complaint (CC)
2. History of Present Illness (HPI)
3. Review of Systems (ROS)
4. PFSH (Past, Family, Social History)
Complexity of medical decision making is based on what three elements?
1. # of Diagnosis or Management options
2. Amount and/or complexity of Data to Review
3. Risk of complication or death if not treated
What are the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of service?
1. History
2. Exam
3. MDM (Medical Decision Making)
What are the four levels of history type?
1. Problem focused
2. Expanded problem focused
3. Detailed
4. Comprehensive
What are the four levels of medical decision making complexity?
1. Straightforward
2. Low
3. Moderate
4. High
What are the three contributing factors?
1. Counseling
2. Coordination of Care
3. Nature of Presenting Problem