These elements would be part of the_____ history: employment, education, use of Drugs.
Social
The level of E/M service is based on:
Key components
The HPI must be documented in the medical record by:
the physician
The observation examination is the ___ portion of the E/M service?
objective
MDM is based on the ____ the physician must consider about the management of a patient's condition.
All of the above
The Hospital Inpatient Services subsection is used for patients admitted to:
An acute care facility
The request for advice or opinion from one physician to another physician is this type of service:
consultation
Critical care codes are reported based on:
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:
Skilled nursing facility
When a physician performs a preventive care service, the extent of the exam is determined by the:
Age
According to E/M guidelines a(n)___ exam encompasses a complete single-specialty exam or a complete multisystem exam.
comprehensive
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 obtains an extended HPI, an extend ROS, and a pertinent PFSH. What is the level of History?
Detailed
The Physician performs an extended exam of the affected body areas and related organ systems. What is the level of the exam?
Expanded Problem Focused
The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?
Moderate
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?
99284
The term used to describe a patient who has NOT been formally admitted to a health care facility is_______
Outpaient
The definition of low birth weight can be found in the notes for subheading
Int'l con't intensive care service
An initial inpatient consulation with a detailed history, detailed exam and MDM of low complexity.
99253
A 40 year-old est. patient presents to the physician office for a preventive care exam
99396
History and Exam of the normal newborn infant born in a hospital setting?
99460
Complete the following blanks that refer to the three factors that the coder must consider in the assignment _____ of service, _____ of service, ______ status
POS, Type, patient
The code range for Home Service is _______
999341-99350
The four types of patient status are____. ____, ______ and _____
New, Est. Inpatient, Outpatient
Matching: Location
Chest
Matching: Quality
Tightness
Matching: Severity
worst I've ever had
Matching: Duration
since last night
Matching: Timining
continous
Matching: Context
on exertion
Matching: Modifying factors
some relief with rest
Matching: Associated signs and systems
some shortness of breath
The most extensive examination that encompasses a complete single specialty examination or complete multisystem examination is___________
Comprehensive
Examination is limited to the affect body area or organ system and other related organ system is________
Expanded Problem Focused
Examination is limited to the affected body area or organ system identified by the chief complaint is _______
Problem-Focused
An extended examination of the affected body area or areas and related organ system(s) is____
Detailed