Ch 11: Content Review Flashcards
Evaluation and Management (30 cards)
What are the three contributing factors?
- Counseling
- Coodination of Care
- Nature of Presenting Problem
The term used to describe a patient who has NOT been formally admitted to a health care facility
Outpatient
Codes from the E/M subsection Nursing Facilities Service are used to report services provided in nursing facilities that used to be known as:
All of the above
The HPI must be documented in the medical record by:
The physician
What are the three key components that are present in every patient case, except counseling encounters or tine-based codes, and enable the coder to choose the appropriate level of service?
- History
- Examination
- Medical Decision Making
According to E/M guidelines, a(n) _____ exam encompasses a complete single-specialty exam or complete multisystem exam.
Comprehensive
The request for advice or opinion from one physician to another physician is this type of service:
Consultation
The code range for Home Services is ______.
99341-99350
These elements would be part of the ______ history: employment, education, use of drugs.
Social
The definition of low birth weight can be found in the notes for subheading ______.
Initial and Continuing Intensive Care Services
The level of E/M service is based on:
All of the above
What are the four elements of history?
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Review of Systems (ROS)
- Past, Family, and/or Social History (PFSH)
The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?
Moderate
Complexity of medical decision making is based on what three elements?
- Number of diagnoses or management options
- Amount and/or complexity of data to review
- Risk of complications or death if the condition is left untreated
When a physician performs a preventive care service, the extent of the exam is determined by the:
Age
Bruising would be an element of review of this organ system.
Hematologic
The Hospital Inpatient Services subsection is used for patients admitted to:
An acute care facility
What are the four levels of medical decision making complexity?
- Straightforward
- Low-complexity
- Moderate-complexity
- High-complexity
Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history?
Detailed
Medical decision making (MDM) is based on the ____ the physician must consider about the management of a patient’s condition.
All of the above
The _____ is a statement describing the reason for the encounter and is a history element.
Chief Complaint (CC)
An established patient is one who has received professional service from the physician or another physician of the exact same specialty and subspecialty in the same group within the past _____ years.
3
The examination is the _____ portion of the E/M service.
Objective
Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward. What is the CPT code?
99341
