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E/M documentation
E/M coding
| Question | Answer |
|---|---|
| The three factors that the coder must consider in the assignment of an E/M code are: 1. Place of Service 2. _____________ of Service 3. Patient Status | type |
| An established patient is one who has received a face-to-face professional service from the same physician or another physician of the same specialty in the same group within the past ____________________ years. | three |
| What term is used to describe a patient who has not been formally admitted to a health care facility? | outpatient |
| The three key components that are present in every patient case except counseling encounters and that enable the coder to choose the appropriate level of service are: 1. history 2. ___________________ 3. medical decision-making | examination |
| The four elements of history are: 1. chief complaint 2. history of present illness 3. past medical history, social history, and ___________________ 4. review of systems | family history |
| The four levels of history type from least complex to most complex are:1. problem focused2. expanded problem focused3. __________________4. comprehensive | detailed |
| A. the most extensive examination, encompassing a complete single specialty examination or complete multisystem examination | comprehensive |
| B. an extended examination of the affected body area or areas and related organ system(s) | detailed |
| C. examination is limited to the affected body area or organ system and other related organ systems | expanded problem focused |
| D. examination is limited to the affected body area or organ system identified by the chief complaint | problem focused |
| Label the following as body area (BA) or organ system (OS): neck | body area |
| Label the following as body area (BA) or organ system (OS): skin | organ system |
| Label the following as body area (BA) or organ system (OS): eyes | organ system |
| Label the following as body area (BA) or organ system (OS): back | body area |
| Label the following as body area (BA) or organ system (OS): respiratory | organ system |
| The four levels of medical decision-making complexity are:1. _______________2. low3. moderate4. high | straighforward |
| The complexity of medical decision-making is based on:1. number of possible diagnoses or management options2. amount or complexity of _________ to review3. risk of complication or death if the condition is left untreated | data |
| The three contributing factors are: coordination of care, nature of presenting problem and _________ | counseling |
| What is the one criterion for selecting a hospital discharge day management code? | Time |
| Who is ultimately responsible for completion of the final examination, follow-up instructions, and arrangements for discharge and discharge records for a hospital inpatient? | Attending physician |
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