1.0 Intro highlights

Question 1

What is a key part of the CC?

Answer 1

Patients have a question

Question 2

1) What should you consider in the middle area between CC and Dx?
2) How do you do this?

Answer 2

1) Do we answer all the right questions in here?
We should consider and document the “Worst case scenarios”
2) Make sure your HPI starts to rule out the worst-case scenario – start checking boxes
To start, make sure you get all of the 7 attributes, every time
Then ask the Key Questions that address severe disease
Make sure your physical exam addresses the right questions
Make sure your tests do the same and are reviewed
Make sure your medical decision making is documented, and reflects what you have done
MDM is your “closing argument”

Question 3

What should you document after Dx?

Answer 3

Document that you discussed follow-up plan with the patient or family and they are comfortable with it

Make sure plan is action and time specific

Question 4

1) For level 5, if you are doing ROS for billing, you want ____ systems and you only need one question in each
2) For level 4, you only need ______ systems

Answer 4

1) 10
2) 2

Question 5

What section of documentation will be entirely focused on the chief complaint and any concerning differentials that arise?

Answer 5

Family and Medical Hx

Question 6

What do you need to document for social Hx?

Answer 6

Generally two items
Ex: Lives at home; Is a smoker/nonsmoker

Question 7

1) T/F: AMA does not mean you are absolved of responsibility.
2) Explain

Answer 7

1) True
2) You must document that they acknowledge the risk of going home and understand the severity of their condition
-You must show that they were an adult with “capacity”
“A and o x 3 and easily and readily know date and year”
-Document that they are not suicidal
-Document that they are welcomed to return at any time
-Yes, you can still treat the patient leaving AMA

Question 8

The selection of the code is now based largely on the MDM in the three following categories, which are? (abbreviated version)

Answer 8

1) Number and complexity
2) Data to be reviewed and analyzed
3) Risk

Question 9

Give the tl;dr of 99282

Answer 9

“straightforward medical decision making”
No data reviewed
No procedures, no prescription, no additional care required

Question 10

Give the tl;dr of 99283

Answer 10

document that test is reviewed, you will meet this section
Low problem complexity

Question 11

Give the tl;dr of 99284

Answer 11

Moderate complexity
Reviewing of external notes
Discussion of management

Question 12

Define High problem complexity

Answer 12

Either 1 chronic illness with severe exacerbation OR 1 illness presenting threat to life or bodily function
-Decision regarding hospitalization

Question 13

T/F: If you use a risk calculator that determines testing is not needed, this counts at the same level as if you had used the test

Answer 13

True

Question 14

Summary: You only need to hit two of the three main categories to bill at a given level; what are the 3 categories?

Answer 14

Complexity
Data
Risk

Question 15

Summary: Documenting ____________ of data (along with justification of the test if not easily inferred) easily meets criteria for “data” through 99284

Answer 15

interpretation

Question 16

Summary:
1) Documenting discussion with other providers and history from _________ sources is beneficial
2) Any __________ involvement increases the complexity
3) Consideration or discussion of ___________ raises the level of risk

Answer 16

1) secondary
2) systemic
3) admission

Question 17

EMTLA:
1) If they’re on your property seeking medical care, you must provide ________________
2) If emergent treatment is required, you must provide what?

Answer 17

1) medical screening exam
2) stabilizing care