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

The level of E/M service is based on: a. documentation b. key components c. contributing factors d. all of the above

The examination is the ? portion of the E/M service. a. subjective b. objective c. assessment d. plan

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

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

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

Critical care codes are reported based on: a. the three key components--history, exam, MDM b. time c. amount of documentation d. procedures performed

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

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

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

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

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

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.

The term used to describe a patient who has NOT been formally admitted to a health care facility is (?)

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: (?)

An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity.CPT CODE: (?)

A 40-year-old established patient presents to the physician office for a preventive care exam. CPT CODE: (?)

History and exam of the normal newborn infant born in a hospital setting. CPT CODE: (?)

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: (?)

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)

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

The code range for Home Services is (?)

The four types of patient status are:

The (?) is a statement describing the reason for the encounter and is a history element.

chest (HPI element?)

tightness (HPI element?)

worst I've ever had (HPI element?)

since last night (HPI element?)

continuous (HPI element?)

on exertion (HPI element?)

some relief with rest (HPI element?)

some shortness of breath (HPI element?)

Examination type: COMPREHENSIVE

Examination type: EXPANDED PROBLEM-FOCUSED

Examination type: PROBLEM-FOCUSED

Examination type: DETAILED

Is the NECK part of the body area (BA) or organ system (OS)?

Is the SKIN part of the body area (BA) or organ system (OS)?

Are the EYES part of the body area (BA) or organ system (OS)?

Is the BACK part of the body area (BA) or organ system (OS)?

Is the RESPIRATORY part of the body area (BA) or organ system (OS)?

What are the four elements of history?

Complexity of medical decision making is based on what three elements?

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?

What are the four levels of history type?

What are the four levels of medical decision making complexity?

What are the three contributing factors?