Transcript Quiz Part 2

Click the Correct Choice
A patient is new if she has not seen another physician
of the same specialty and in the same practice group
for the past
A. 1 year
B. 2 years
C. 3 years
D. 4 years
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A patient is new if s/he has received no care by a
member of the billing physician’s same specialty and
practice group in the past 3 years.
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Click the Correct Choice
No CPT code can be submitted without
documentation of
A. Chief Complaint
B. History of present illness
C. Physical exam
D. Assessment and plan
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A chief complaint is required for all CPT E &M codes.
For established patients, only 2 of 3 key components
must meet documentation requirements for CPT level.
Even without documentation in one key area, a CPT
code can still be reimbursed.
Documentation should of course meet medical standards for
clarity and completion aside from the billing standard minimums!
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Click the Correct Choice
The following counts as assessment of past medical
history
A. Allergies
B. Past surgical history
C. Medications
D. All the above
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Allergies, medications, gynecologic history,
preventive care history, immunizations, and prior
surgical procedures are all considered assessment of
past medical history.
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Click the Correct Choice
You see an established patient for a new problem. You document a
“detailed” HPI by using 4 or more historical descriptors. You also
document the patient’s allergies and medications, which count as
past medical history. You ask many ROS questions as well.
How many of the ROS findings will you need to document for your
history documentation to support coding level 4?
A. none
B. 1
C. 2
D. 10
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Click the Correct Choice
For an established patient, examination of how many
organ systems must be documented to support level
5 coding?
A. 2
B. 5-7
C. 8
D. 10
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Some institutions and
Medicare intermediaries
have defined level 4 “2Detailed” documentation
requirements
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Click the Correct Choice
A patient has 3 chronic problems requiring management. You need
to review prior labs, review a bone density result, and order
pulmonary function testing. The medical decision making level is:
A. Moderate, supporting a level 4 code, because 3 diagnoses are
present and 3 data review points are present (review lab, review
radiology, order other test).
B. High, supporting a level 5 code, because you are managing 3
chronic problems and managing lots of data.
C. Low, supporting a level 3 code, because 3 diagnoses are present
but only 2 data review points are tallied (review tests, order test).
D. You can’t tell until the risk level is decided.
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Medical decision making level is determined by the higher 2 of
the 3 subcomponent areas. Review of lab tests and ordering of
lab tests each count as a separate data review point.
You’ve completed Quick Quiz #2.
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101
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