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Code assignment in the E/M section varies according to three factors:
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Factor in code assignment that explains the setting in which the services were provided.
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Week 4 CPT
Week 4 Review
| Question | Answer |
|---|---|
| Code assignment in the E/M section varies according to three factors: | Place of service, type of service, and patient status |
| Factor in code assignment that explains the setting in which the services were provided. | Place of service |
| Factor in code assignment that is the reason the service is requested or performed. | Type of service |
| Factor in code assignment that establishes what type of patient you are coding for. | Patient status |
| A written or verbal request from one provider/physician to another to obtain an opinion and/or advice about a diagnosis or management options. | Consultation |
| Attention to an acute illness or injury that results in admission to a hospital. | Admission |
| The evaluation and determination of care management of a newly born infant. | Newborn care |
| A face-to-face encounter between a physician and a patient to allow for primary management of the patient's health care status. | Office visit |
| What are the four types of patient status? | New patient, established patient, outpatient, inpatient |
| Patient who has not received professional face-to-face services from the physician or another physician of the same specialty in the same group within the past 3 years. | New patient |
| Patient who has received professional face-to-face services from the physician or another physician of the same specialty in the same group within the past 3 years. | Established patient |
| Patient who has not been formally admitted to a health care facility or a patient admitted for observation. | Outpatient |
| Patient who has been formally admitted to a health care facility. | Inpatient. |
| Patient information is located in the medical record. This information is referred to as? | Documentation |
| The levels of service are based on? | Key components and contributory factors |
| What are the key components that the levels of service are based on? | History, examination, and medical decision making. |
| Key components are present in every patient case except? | Counseling centers |
| The subjective information the patient tells the physician based on the four elements: CC, HPI, ROS, and PFSH. | History |
| The documentation of history is found in the patient's medical record and is recorded by? | The physician |
| The four elements of a history: | Chief complaint, history of present illness, review of systems, and past, family, and/or social history. |
| A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words. | Chief Complaint (CC) |
| A chronological description of the development of the patient's present illness from the first sign and/or symptom from the previous encounter to the present. | History of Present Illness (HPI) |
| An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. | Review of Systems (ROS) |
| The patient's past experience with illnesses, operations, injuries, and treatments. | Past history |
| An age-appropriate review of past and current activities. | Social history |
| A review of medical events in the patient's family. | Family history |
| The degree or level of HPI, ROS, and PFSH is determined by? | The chief complaint or presenting problem of the patient. |
| What are the four history levels? | Problem focused, expanded problem focused, detailed, and comprehensive |
| History level in which the physician focuses on the chief complaint and a brief history of the present problem of a patient. | Problem focused |
| History level in which the physician focuses on a chief complaint, obtains a brief history of the present problem, and also performs a problem pertinent review of systems. | Expanded problem focused |
| History level in which the physician focuses on a chief complaint, obtains and extended history of the present problem, and extended review of systems, and or pertinent PFSH. | Detailed |
| History level in which the physician documents the chief complaint, obtains and extended history of the present problem, does a complete review of systems, and obtains a complete PFSH. | Comprehensive |
| When selecting a history level, the choice goes to? | The lowest level |
| Information regarding the complaint or problem in the history portion of the encounter. | Subjective information |
| Information that contains the findings observed by the physician about the complaint or problem. | Objective information |
| What are the four examination levels? | Problem focused, expanded problem focused, detailed, and comprehensive |
| Examination level in which the examination is limited to the affected body area or organ system identified by the chief complaint. | Problem focused |
| Examination level in which a limited examination is made of the affected body area or organ system and other symptomatic or related body area(s)/organ system(s). | Expanded problem focused |
| Examination level in which an extended examination is made of the affected body area(s) and other symptomatic or related organ system(s). | Detailed |
| Examination level that encompasses a general multi-system examination and should include findings about 8 or more of the 12 organ systems. | Comprehensive |
| What are the three key components of an E/M service? | Examination, history, medical decision making |
| The extent of the ROS depends on the _____. | Patient complaint |
| If the patient record indicates that the physician queried the patient as to weight changes, fever, weakness, and fatigue, what category of the ROS would this query belong in? | Constitutional symptoms |
| In which level of examination is a complete multisystem examination performed? | Comprehensive |
| In which level of examination is a limited examination of the affected body area or organ system reviewed? | Problem focused |
| is based on the number of possible diagnoses and/or the various ways the diagnosis can be treated. | number of diagnoses or management options |
| There are four levels of risk assessment: | Minimal, low, moderate, high |
| Risk is usually self-limiting. An example is a patient who presents with a wasp sting. | Minimal |
| Risk is several minimal factors or one factor that is more than minimal. An example is a patient who presents with numerous wasp stings. | Low |
| Risk is one chronic condition such as diabetes, or two or more stable but chronic conditions, such as high blood pressure and diabetes both controlled with medication. | Moderate |
| Risk is an illness or injury that is life-threatening, such as a myocardial infarction or cardiac arrest. | High |
| When MDM Complexity is _________, The number of diagnoses or management options is minimal. The amount and/or complexity of data are minimal or none. The risk of complication or death is minimal. | Straightforward |
| When MDM Complexity is _____, The number of diagnoses or management options is limited. The amount and/or complexity of data are limited. The risk of complication or death is low. | Low |
| When MDM Complexity is __________, The number of diagnoses or management options is multiple. The amount and/or complexity of data are moderate. The risk of complication or death is moderate. | Moderate |
| When MDM Complexity is _____, The number of diagnoses or management options is extensive. The amount and/or complexity of data are extensive. The risk of complication or death is high | High |
| Minimal diagnoses and management options would be a part of which level of medical decision making? | Straightforward |
| The __________ presenting problem may not require the physician to be in attendance. Some examples are a dressing change or removal of an uncomplicated suture. | Minimal |
| The __________ presenting problem is a minor problem that will run its course with a good outcome predicted. | Self-limiting |
| The __________ presenting problem is one in which without treatment there is a low risk of increasing sickness and a low risk of death. An example is a middle-aged, healthy male with an upper respiratory infection. | Low |
| The __________ presenting problem is one in which without treatment there is a moderate risk of increasing sickness and a moderate risk of death. | Moderate |
| A __________ presenting problem is one in which without treatment there is a high risk of increasing sickness and a high risk of death. | High |
| If a patient was seen in the office by his physician on Monday and during the appointment the physician decided to admit the patient to the Observation Unit of the local hospital, would you code both the office service and the observation service? | No |
| Is the first service provided to the patient by the attending physician and includes admission to the hospital and the initial plan with orders. | Initial hospital care |
| Is provided after the initial services of admission and the initial plan. | Subsequent Hospital Care |
| Are provided the final day of the hospital stay when the patient has been in the hospital for more than 1 day. | Hospital discharge services |
| The physician who admits the patient and is responsible for the patient during the stay in the inpatient facility. | Attending physician |
| A physician whose opinion and advice is requested by another physician. | Consultant |
| The care given to the patient by more than one physician at the same time. | Concurrent care |
| What is the name of the service when one physician asks another physician for advice? | Consultation |
| When coding critical care services, you would code the 30-74 minutes and then for each _____ minutes after 74. | 30 |
| When coding prolonged services, you would not report time that is less than _____ minutes. | 30 |
| When reporting Physician Standby, the physician cannot be: | Providing services to another patient. |
| Medical Team Conference services are billed on the basis of time in blocks of ___________ minutes. | 30 |
| An annual checkup is an example of which type of service? | Preventative management |
| A patient comes into your physician's office for a physical examination for a life insurance policy. What group of codes would you use to report this service? | Special evaluation and management services. |
| Disability insurance examinations are coded using the Special _______________ and Management Services. | Evaluation |
| If a physician encounters a problem during the course of a preventive service and the service requires significant additional service, you could code an office code along with which modifier? | -25 |
| Which government group is responsible for the Medicare program? | Centers for Medicare and Medicaid Services |
| The Documentation Guidelines apply only to this group of codes: | E/M |
| E/M services represent which percent of all services provided to Medicare and Medicaid patients? | 50% |
| CMS stands for: | Centers for Medicare and Medicaid Services |
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