Medical Coding Chapter 10

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Med Coding CH 10

Office

Where is the place of service?

office visit or other outpatient service

What is the type of service?

New

What is the patient status?

99201

What is the first code number listed under the subheading New Patient?

5

Each code represents a different level of service. How many codes are listed under Office or Other Outpatient Services for a new patient?

5

How many codes are listed for the established patient in the Office or Other Outpatient Services category?

exceed, three

The above categories/subcategories must meet or ________________ of three key components.

True

Some history elements may be documented by ancillary staff or the patient.True or False?

Problem focused, expanded problem focused, detailed, and comprehensive

Levels of history required in documentation of the Chief Complaint (CC)?

lowest level

When selecting a history level, the choice goes to the __________.

majority

When selecting an MDM level, the choice is the _____________.

Yes

Could a physician assign 99211 to report a patient encounter?

outpatient

Are observation codes 99218-99220 reported for inpatient or outpatient services?

time

What is the one criterion for selecting a hospital discharge day management code?

30 minutes or less, more than 30 minutes

What are the times indicated for each of the Hospital Discharge Services codes?

written or verbal request

Criteria required to report a consultation include: ___________ from the attending to the consultant to see the patient.

report

Evaluation of the patient by the consultant _________ back to the attending of the findings and recommendations of the consultant.

None

What are the times associated with codes 99281-99285?

99285

If a patient presents to the emergency dept. in a clinically life-threatening state that prevents the physician from performing a complete history or physical examination, what is the code?

self-limited or minor

The severity of the presenting problem for Code 99281 would usually be?

high

The severity of the presenting problem for Code 99284 would usually be?

moderate

The severity of the presenting problem for Code 99283 would usually be?

low to moderate

The severity of the presenting problem for Code 99282 would usually be?

notes preceding

There are many rules that govern the calculation of time when determing the codes in the Prolonged Services codes. Where are they located?

written request

To report standby services, there must be a _____________ for standby services in the medical record.

30 minutes or more

What is the time component specified in the Medical Team Conference codes from the Case Management Services subsection?

age

According to the notes in the Preventive Medicine Services subsection, the extent and focus of the services provided, whether to a new or established patient, will depend largely upon what factor?

body area

Is examination of the back an organ system or body area examination?

four types of patient status

New, Established, Inpatient, and Outpatient.

initial, subsequent

The first outpatient visit is called the ________ visit, and the second visit is called the ________ visit.

status, type of service, and place of service

The first three factors a coder must consider when coding a patient are?

four

How many types of histories are there?

expanded problem focused

Which history is more complex: the problem focused history or the expanded problem focused history?

problem focused, expanded problem focused, detailed, and comprehensive

What are the 4 types of examinations, in order of difficulty (least to most difficult)?

problem focused

The examination that is limited to the affected body area is?

Very Low Birth Weight

What does VLBW stand for?

straightforward

What medical decision making involves a situation in which the diagnosis and management options are minimal, data amount and complexity and must be reviewed are minimal/none, and there is a minimal risk to the patient of complications or death?

inpatient

What term is used to describe a patient who has been formally admitted to a hospital?

consultation

Advice or opinion from one physician to another physician.

admission

Attention to an acute illness or injury that results in hospitalization.

office visit

A face-to-face encounter in an office between the physician and patient

newborn care

Evaluation and determination of care for a newborn infant

established patient

One who has received services from the physician or another physician in the same group within the last 3 years

inpatient

One who has been formally admitted to an acute health care facility

new patient

One who has not received services from the physician or another physician in the same group within the last 3 years

outpatient

One who has not been formally admitted to a health care facility

high, moderate, low, and straightforward

Four types of medical decision making, in order of complexity from most to least complex.

elements

Complexity of medical decision making is based on three _______.

contributory

Counseling and coordination of care are what kind of factors in most cases?

face-to-face or direct

Time that is used as a guide for outpatient services is what kind of time?

unit/floor

Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time?

medical record

The patient's __________ will reflect the number of systems examined by a brief statement of the findings.

counseling

A discussion w/a patient and/or family concerning 1 or more of the following areas: diagnostic result, impressions, and/or recommended diagnostic studies; prognosis; risks & benefits of treatment; instructions for treatment; importance of compliance w/treatment; risk factor reduction; and patient and family education is?

subjective

The history is the _______ information the patient tells the physician.

emergency

There is no distinction made between the new and established patients in this service department of a hospital:

consultation, attending

Those services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation and/or treatment of a patient is a(n) _________, whereas the physician who has primary responsibility for the patient in the hospital is called ________.

critical care

When critically ill patients in medical emergencies require the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, and respiratory failure) to stabilize them, what kind of care is needed?

concurrent

When care is provided for similar services (e.g., hospital visits) to the same patient by more than one physician on the same day for different conditions, the care is?

transfer of care

What is the name for the assumption of the total or specific care of a patient from one physician to another that does not constitute a consultation?

review of systems

An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a(n)?

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