E/M coding
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| show | 99
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| show | place of service, nature of the presenting problem, time spent of the service, and the content/extent/level of the service.
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| show | Evaluation and Management
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| show | beginning of CPT manual
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| Where are E/M codes generally found on an encounter form? | show 🗑
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| A ______ patient has not received any face -to -face professional services from this physician or another physician of the same specialty at your facility within the last three years. | show 🗑
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| A _______ patient has received face-to-face professional services from this physician or another physician of the same specialty at your facility within the last three years. | show 🗑
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| What components must be considered before determining the level of E/M service to report? | show 🗑
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| How many key components are there - name them | show 🗑
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| show | All 3 key components are needed for a new patient for outpatient services.
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| When reporting an outpatient service for an established patient, does the coder need all three key components before reporting the E/M code? | show 🗑
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| What are the contributing components? | show 🗑
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| show | seven components for E/M coding
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| show | Contributing Components
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| What are the four elements of History? | show 🗑
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| What is CC? | show 🗑
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| What is HPI? | show 🗑
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| What is ROS? | show 🗑
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| show | Past Medical, Family and Social History
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| show | CC - Chief Complaint
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| What are the eight elements of HPI? | show 🗑
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| HPI is based on the number of elements. It can be either _______ HPI or _____ HPI. | show 🗑
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| show | Extended
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| If the report has 1-3 elements, it will be a _____ HPI. | show 🗑
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| Concerning HPI, what are these an example of: hand, head, foot, etc.. This is 1 of the 8 elements of HPI | show 🗑
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| show | quality
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| Concerning HPI, what are these examples of: mild, intense, horrible; some may use a scale to decide this, such as "on a scale from 1-10, how would you rate your pain" This is 1 of the 8 elements of HPI | show 🗑
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| show | Duration
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| Concerning HPI, what is this an example of: "after eating, after exercise"This is 1 of the 8 elements of HPI. | show 🗑
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| Concerning HPI, what is this an example of: "when slumping," "only when sitting," "while running" This is 1 of the 8 elements of HPI and it identifies symptoms associated with a situation. | show 🗑
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| show | Modifying factors
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| show | associated signs and symptoms
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| A _______ _________ ROS is a review of the one body system that is directly related to the chief complaint or presenting problem. | show 🗑
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| show | Extended
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| A ________ ROS is a review of 10 or more body systems | show 🗑
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| show | ROS
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| show | level
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| What is OS? | show 🗑
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| show | Body Area
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| How many levels are there of PFSH? | show 🗑
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| show | 1 item from the past
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| show | 2 items from 2 areas
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| For a PFSH to be Complete, it must have how many items from the past for a new patient? | show 🗑
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| show | yes
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| What are elements of Past and Social History | show 🗑
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| show | yes
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| show | 1. Problem focused2. Detailed3. Expanded problem focused4. Comprehensive
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| show | AMA & CMS
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| show | Time
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| What must support the code selection? | show 🗑
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| show | problem focused history
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| If the physician centers his attention on the CC, obtains brief history of present problem, performs a problem pertinent ROS, what type of history is it? | show 🗑
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| If the physician focuses on the CC, obtains an extended history of present problem, an extended ROS, and a pertinent PFSH, what type of history is it? | show 🗑
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| show | comprehensive history
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| show | problem focused exam
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| show | expanded problem focused exam
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| show | detailed exam
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| If the exam is extensive, consists of a complete single-specialty exam or complete multisystem exam, what type of exam is is? This is the most complex exam. | show 🗑
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| show | initial
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| What is the second visit? | show 🗑
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| show | lowest
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| What are the medical decision making complexity levels? | show 🗑
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| When selecting the MDM level, the coder will select the ______. In other words, select the level of the higest two. | show 🗑
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| What is MDM based on? | show 🗑
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| What type of MDM is this: * minimal diagnosis and management* data and complexity are minimal/none* minimal risk | show 🗑
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| What type of MDM is this:* limited # of diagnoses & management* limited data* low risk | show 🗑
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| What type of MDM is this:* multipul diagnoses & management * moderate complexity & data* moderate risk | show 🗑
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| What type of MDM is this:* extensive diagnoses & management* extensive complexity & data* high risk | show 🗑
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