Coding chapter 4 E/M codes study guide (part 1)

A consultation requested by the patient is coded as a

New patient visit

What does the acronym PFSH stand for

Past, family, and social history

A patient comes in with one or two possible diagnosis, is on no medication, and has no other co-morbidities. The level of decision making would be:

Straightforward

A small number of possible diagnosis and treatment options are described as medical decision-making that is:

Straightforward

Locations that will help determine an E/M code include all of the following except

Surgical operating rooms

PFSH includes all of these components except

Systems history

To assign a correct E/M code, you must know:

The location of the encounter

Emergency department E/M codes are determined by:

Three key components

An E/M code to report an office visit with a new patient requires:

Three of the three key components

Dr. getter spent one hour with Nancy, 40 minutes of which he spent counseling her on keeping her diabetes under control. The primary factor for this E/M code is the:

Time

A consultation is defined as _ at the request of another physician

When a physician provides advice or an opinion on a patient's treatment

The amount of detail involved in the documentation of the patient history that has been taken during this encounter

Will identify the level of patient history

An established patient is defined as:

A patient who has been seen within the last 3 years

A general Multi-system examination is described as:

Comprehensive

Level of history obtained include:

Comprehensive

Level of medical decision-making include all of the following except:

Comprehensive

A consultation requested by another physician is coded as an

Consultation

E/M services provided to an assisted living facility resident are coded:

Domiciliary subsection

In what section of the CPT code book are E/M codes listed

Evaluation and management

When a patient has a detailed history, the review of systems must fall into which category

Extended problem-pertinent review of systems

What services do evaluation and management codes report

Physician encounter

One of the organ systems recognized by the CPT is the:

Psychiatric

The CPT book categorizes:

Seven body areas and eleven organ systems

All of these body areas are recognized by CPT, except the:

Skin

Time can be used to determine an E/M code when:

More than 50 percent of the total time is spent counseling the patient

An example of an organ system is the

Neurologic

A patient came in to see the specialist in your office for the first time. What is the patient's relationship?

New patient

Darlene has not seen Dr. Curtis in four years. Today's visit will be coded as a?

New patient

Medical decision-making is measured by the:

Number of possible diagnosis and the number of possible treatments

Consultation services are coded based upon who requested the service and the:

Office or hospital location

A patient was admitted and discharged on the same date of service. From what range will the physician's E/M services be reported?

99234-99236

An example of a body area is the:

abdomen

A patient was admitted into the hospital by Dr. Alaska. He has been in to see her every day. What would the code range be for his visit on day three?

99231-99233

The amount of time spent may be used as the key element to determine an E/M code when counseling takes more than:

50 percent

What code is reported for a physician who provided discharge services for a patient who is being discharged from observation care after a two-day stay?

99217

An example of a body area is the

Abdomen

A patient history may consist of

All of these

The relationship between provider and patient, as described by E/M codes, may be a

Any of these

When a pt has several possible diagnosis and has a high risk of significant complications from the standard treatment, The MDM would fall into which category?

High complexity

What does the level of medical decision-making describe?

How much knowledge and expertise the provider used to determine the diagnosis and treatment plan

George sees Dr. Mallard in his office. Dr. Mallard sends George immediately to be admitted into the hospital. The E/M code will be chosen from subsection:

Initial hospital care

Key components of some E/M codes include:

Level of examination

An E/M code is determined first by the encounter's:

Location

The patient comes in with a broken bone sticking out from his arm. The level of MDM from the physician to determine what to do next is

Low complexity