E/M coding
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| E/M codes all begin with what two numbers? | 99
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| What does E/M codes describe or identify? | 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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| What does E/M mean? | Evaluation and Management
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| E/M codes are found in what part of the manual? | beginning of CPT manual
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| Where are E/M codes generally found on an encounter form? | within the first section to complete
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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. | new patient
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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. | established patient
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| What components must be considered before determining the level of E/M service to report? | History, examination, and MDM
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| How many key components are there - name them | Three: History, examination, and MDM
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| When reporting an outpatient service for a new patient, does the coder need all three key components before reporting the E/M code? | 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? | The coder only needs 2 of the 3 key components to report an outpatient service for an established patient.
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| What are the contributing components? | Extent of counseling, Coordination of care with others, Nature of presenting problem(s), and Time
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| What are these? • Key components (KC)1. History2. Examination3. Medical decision making• Contributing components:4. Extent of counseling5. Coordination of care with others6. Nature of presenting problem(s)7. Time | seven components for E/M coding
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| What components are factored in, as applicable?Key Components or Contributing Components? | Contributing Components
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| What are the four elements of History? | 1). chief complaint (CC)2). history of present illness (HPI )3). review of systems (ROS)4). past,family,and social history (PFSH)
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| What is CC? | Chief Complaint
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| What is HPI? | History of Present Illness
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| What is ROS? | Review of Systems
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| What is PFSH? | Past Medical, Family and Social History
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| The ______ includes the symptoms, reason(s) for the visit, stated problem of the patient, signs, and diagnosis (if any were established prior to the visit). | CC - Chief Complaint
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| What are the eight elements of HPI? | location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
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| HPI is based on the number of elements. It can be either _______ HPI or _____ HPI. | Brief or Extended
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| If the report has 4-8 elements, it will be an ______ HPI | Extended
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| If the report has 1-3 elements, it will be a _____ HPI. | Brief
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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 | location of the symptom
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| Concerning HPI, what are these an example of: burning, fullness. This is 1 of the 8 elements of HPI. | 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 | serverity
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| Concerning HPI, what is this an example of: "since last month" "since two days ago" This is 1 of the 8 elements of HPI and it explains how long the patient suffered. | 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. | timing
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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. | Context
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| Concerning HPI, what is this an example of: "sitting up straight," "cold compress" This is 1 of the 8 elements of HPI and it identifies the factors that make the condition better, or worse. | Modifying factors
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| Concerning HPI, what are these examples of: "hard to swallow, chest pain" This is 1 of the 8 elements of HPI and it tells of the problems that happen at the same time as another problem. | 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. | Problem pertinent
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| An ________ ROS is a review up to 9 additional systems | Extended
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| A ________ ROS is a review of 10 or more body systems | Complete
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| ________ is the inventory of the body systems | ROS
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| The number of systems reviewed and documented determines the _____ of ROS selected. | level
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| What is OS? | Organ System
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| What is BA? | Body Area
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| How many levels are there of PFSH? | 2: Pertinent and Complete
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| For a PFSH to be Pertinent, it must have how many items from the past? | 1 item from the past
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| For a PFSH to be Complete, it must have how many items from the past for an established patient? | 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? | 3 items out of 3 areas
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| For a Complete PFSH, does it matter if the patient is new or established concerning how many items from the past should be obtained? | yes
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| What are elements of Past and Social History | Major illnesses/injuriesOperations HospitalizationsAllergiesImmunizationsDietary statusSexual historyOther relevant social factors
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| Are the types of History and the types of Examination the same? | yes
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| What are the types of History and Examination? | 1. Problem focused2. Detailed3. Expanded problem focused4. Comprehensive
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| Who developed the E/M Coding Guidelines? | AMA & CMS
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| Sometimes the case may mostly consist of counseling or coordination of care. What factor would the coder use to code this service? | Time
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| What must support the code selection? | Documentation
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| If the physician focuses on the CC, and a breif history of the present problem, what type of history is it? | 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? | expanded problem focused history
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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? | detailed history
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| If the physician documents the CC, does an extended history of present problem, complete ROS, and complete PFSH, what type of history is is? This is the most complex history type. | comprehensive history
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| If the exam is limited to the affected BA, or OS, identified in CC, what type of exam is it? | problem focused exam
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| If the exam is limited, made of affected BA or OS, and other symptomatic or related BA's / OS's, what type of exam is it? | expanded problem focused exam
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| If it is an extended exam concerning the affected BA, and other symptomatic or related OS, what type of exam is it? | 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. | comprehensive exam
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| What is the first visit? | initial
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| What is the second visit? | subsequent
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| When selecting a history level, the coder should select the ______ level. | lowest
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| What are the medical decision making complexity levels? | Straightforward decision makingLow-complexity decision making,Moderate decision making,High-complexity decision making
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| When selecting the MDM level, the coder will select the ______. In other words, select the level of the higest two. | majority
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| What is MDM based on? | the number of diagnoses or management options. The amount or complexity of data to review. The risks of complication or death if the condition goes untreated
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| What type of MDM is this: * minimal diagnosis and management* data and complexity are minimal/none* minimal risk | straightforward decision making
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| What type of MDM is this:* limited # of diagnoses & management* limited data* low risk | low-complexity decision making
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| What type of MDM is this:* multipul diagnoses & management * moderate complexity & data* moderate risk | moderate-complexity decision making
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| What type of MDM is this:* extensive diagnoses & management* extensive complexity & data* high risk | high-complexity decision making
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