Coding

Question 1

T/F: Using a template function in EMR when documenting a visit is recommended due to time-saving ability.

Answer 1

False

Question 2

In regards to the Medical Decision Making Criteria, new patient visits or consults (in-house or outpatient) require you to fulfill which of the following in your note?
A.Number of Diagnoses or Management Options
B.Risk of Complications and/or morbidity or mortality
C.Amount and/or Complexity of Data to be Reviewed
D.Two of the three listed above
E.A, B and C

Answer 2

E

Question 3

What is/are the most common reason(s) for inadequate documentation (and therefore billing reimbursements)?
A.History
B.Review of Systems
C.Past/Family/Social History (PFSH)
D.A and B
E.B and C

Answer 3

E

Question 4

T/F: When “grading” the level of documented History and/or Medical Decision Making for purposes of billing, the level of the highest element will denote the level used for billing.

Answer 4

False