USCI Medical Billing & Coding, Components of Evaluation and Management, Quiz 37

7. Which decision making level, according to the table for "Diagnosis and Management Options," is used for an established patient with a new problem with no additional work-up planned?

C. Multiple

21. Patient is seen by a cardiologist for an office consultation

B. 99241-99245

32. Determine the overall level of service.

B. 99283

40. What is the overall level of service for this scenario?

B. 99283

24. Rest home visit for a new patient

B. 99324-99328

2. Which element is part of the medical decision making component?

D. All of the above

22. A new patient is seen at an allergy clinic

A. 99201-99205

23. Inpatient consultation for an established patient

A. 99251-99255

9. Which is a false statement of key components?

A. All E/M codes require all three key components when determining the level of service.

SUBJECTIVE A 47-year-old male is admitted to the emergency department. He has been feeling fatigued and has had a cough and swollen feet for the past week. Two hours prior to admission, he was awakened by difficulty breathing and chest tightness. OBJECTIVE Blood pressure is normal. Patient is afebrile. HEENT normal. Cardiovascular exam notes rumbling apical diastolic murmur with presystolic accentuation. Crackles heard on respiratory exam. Feet are swollen. Chest x-ray, echocardiogram and ECG are ordered. Chest x-ray shows signs of pulmonary edema. ASSESSMENT Patient suffers from rheumatic mitral stenosis. PLAN He will be admitted by his PCP for additional workup.

A. CC: chest tightness HPI: Location - chest; AS&S - difficulty breathing; Duration - two hours ROS: Constitutional - fatigued; Respiratory - cough; Integumentary - swollen feet PFSH: n/a

1. Which is a characteristic found in the HPI element?

A. Context

11. Based on the following question, which HPI characteristic would apply: "In what setting does the problem occur?"

A. Context

35. Determine the best audit summary for the medical decision making component for the highest level of service.

A. Dx/Mgmt: New to doctor, no additional work-up planned = Multiple Data: = Minimal or None Risk: Acute/chronic illness that poses threat to life or function = High

26. Determine the best audit summary for the examination component for the highest level of service.

A. Gastrointestinal - anusHematologic/Lymphatic/Immunologic - blood test

17. Which is a true statement of the chief complaint?

A. It is a statement describing the reason for a particular encounter.

36. Determine the overall level of service.

B. 99203

28. Determine the overall service for this scenario.

B. 99213

38. What is the level of service for the examination component?

C. Detailed

27. Determine the best audit summary for the medical decision making component for the highest level of service.

C. Dx/Mgmt: New to doctor, no additional work-up planned = Multiple Data: Pathology & Lab (1) = Minimal or None Risk: Prescription drug management = Moderate

12. Which is a false statement of the examination component?

C. It is subjective or fiction.

8. What level of risk is "diagnostic endoscopies with no identified risk factors" in the Table of Risk?

C. Moderate

39. What is the level of service for the medical decision making component?

C. Moderate Complexity

20. Which HPI characteristic would apply: "What helps?"

C. Modifying Factors

15. This refers to the setting where the services were provided to the patient.

C. Place of service

4. Marital status, employment, level of education and sexual history are examples of this.

C. Social history

16. Which HPI characteristic would apply: "How long does the pain last?"

C. Timing

14. Which is a false statement of the review of systems?

C. You obtain this information from the examination portion of the report.

SUBJECTIVE A 19-year-old female is seen by her PCP in his office complaining of a sore on her buttocks. The sore was noted about 13 days ago. OBJECTIVE Anus was examined. Blood tested positive for syphilis. ASSESSMENT Primary anal syphilis. PLAN Patient discharged with prescription for antibiotics.

B. CC: sore HPI: Duration - 13 days ago ROS: Integumentary - sore on buttock PFSH: n/a

30. Determine the best audit summary for the examination component for the highest level of service.

B. Constitutional -afebrile ENMT - HEENT Cardiovascular - apical diastolic murmur Respiratory - crackles Each extremity - swollen feet

6. This is described as one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

B. Established patient

HISTORY CHIEF COMPLAINT Pain and deformity of the distal right forearm. HISTORY OF PRESENT ILLNESS The patient was in good health until today when he tripped over a Doberman while walking down a sidewalk. He fell on his outstretched arm, resulting in severe pain and deformity of the distal right forearm. PAST HISTORY Social history: Does not smoke, drink or use recreational drugs. REVIEW OF SYSTEMS Noncontributory. PHYSICAL EXAMINATION GENERAL: The patient appears in some distress with acute pain in the distal right forearm. VITAL SIGNS: Pulse: 78. Blood pressure: 150/88. Temperature: Normal. HEENT: PERRLA. NECK: Supple. CHEST: Clear. No cardiac murmurs. Regular rate and rhythm. EXTREMITIES: There is palpable deformity over the distal radius with 1/5 opposition and strength in the right hand and 4+ swelling in the right wrist. NEUROLOGIC: Focal neurologic deficit to pinprick at the site of maximal tenderness in the distal right forearm. Decreased DTRs in the RUE. DATABASE X-ray confirms Colles fracture. ASSESSMENT Colles fracture. RECOMMENDATIONS Refer to orthopedic surgery clinic for reduction and immobilization. Right forearm sling and wrist immobilizer.

B. Expanded problem focused

10. This component consists of chief complaint, history of present illness, review of systems and past, family and/or social history.

B. History

3. Which is a false statement of time?

B. If you aren't sure of the E/M level, code it based on the time the physician spent with the patient.

19. Which elements does the E/M use as a classification system to determine a code range?

B. Place of service, type of service and patient status

34. Determine the best audit summary for the examination component for the highest level of service.

D. All are possible examination audits and have the same level of service.

5. Which is an example of a place of service?

D. All of the above

HISTORYA 22-year-old African-American male comes to the clinic with pain due to sickle-cell disease and requests pain medicine. He has never come to this clinic before; he usually goes to the one across town, but he "cannot be bothered with those docs because they never give enough pain medicine." When asked how much pain he has, he states it is a 15/10. The patient is writhing in pain. The doctor assesses the patient and addresses the need for pain control. PAST MEDICAL HISTORY Sickle-cell disease, pneumonia. NKDA. Family history: Sickle-cell trait, hypertension. Social history: None. REVIEW OF SYSTEMS Painful extremities. No fever. No chest pain. No respiratory distress. PHYSICAL EXAMINATION GENERAL: Patient writhing in pain. VITAL SIGNS: Temperature 98.6 ºF, heart rate 110, respiration rate 20, blood pressure 135/80. HEENT: EOMI. PERRL. Clear TM. CARDIORESPIRATORY: Sinus tachycardia, normal S1/S2, no murmurs, rubs or gallops. Lungs: CTA bilaterally. ABDOMEN: Soft, nondistended, diffusely tender. EXTREMITIES: No clubbing, cyanosis, edema. Pain everywhere. NEUROLOGIC: Grossly intact. ASSESSMENT Sickle-cell crisis. PLAN The patient's painful crisis was appropriately treated with a shot of Demerol. There was no fever and no perceived infection. Consequently, no labs were obtained. The patient was new to this clinic, and the physician patient interaction was appropriate. The patient was discharged home on oral pain medication and told to follow up as needed.

D. Both a and c are correct and code to the highest level of service for this component.

31. Determine the best audit summary for the medical decision making component for the highest level of service.

D. Dx/Mgmt: New to doctor, additional work-up planned = Extensive Data: Radiology (1); Medicine Studies/Tests (1) = Limited Risk: Acute/chronic illness that poses threat to life or function = High

18. NO ALLERGIES is documented in the subjective area of a report. Where do you categorize this information?

D. Either a or c

13. According to the Table of Risk, what is the level of risk for the decision not to resuscitate due to poor prognosis?

D. High