The Next Step- Chapter 1

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****All of the true or false questions are TRUE!!!

What are three factors of E/M codes?

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

Place or setting in which the service was provided is called?

Place of service

There are different codes for outpatient and inpatient settings.

True

Kind of service provided is called?

Type of service

Codes are divides based on the types of service.

True

How many types of patients statuses are there?

four

Has not received professional services from the physician or another physician of the same specialty and sub specialty in the same group practice within the past 3 years.

New patient

has received professional services from the physician or another physician of the exact same specialty and sub specialty in the same group practice within the past 3 years.

Established patient

Has not been formally admitted to a health care facility.

Outpatient

Has been formally admitted to a health care facility.

Inpatient

The three key components are the history, examination,and a medical decision-making complexity.

True

Is the subjective (patient provided) information that the physician elicits regarding to the chief complaint

History

There are four elements of history.

True

What are the four elements of history?

Chief Complaint(CC), History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and Social History (PFSH)

CC

Chief Complaint

HPI

History of Present Illness

ROS

Review of Systems

PFSH

Past,Family, and Social History

A concise statement describing the symptom,problem,condition,diagnosis,physician recommended return or other reason for the encounter/ visit usually in patient's words is called a

chief complaint

Is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present

History of Present Illness

Location means

Site on the body

Quality means

Characteristics, such as throbbing, sharp

Severity means

How intense or on a scale of 1/10

Duration means

How long for this problem or episode

Timing means

When does it occur

Context means

Under what circumstances does it occur

Modifying factors means

What makes it better or worse

Associated signs and symptoms means

what else is happening when it occurs

The extent of the HPI as problem focused, expanded problem focused, detailed, or comprehensive is based on the physician's professional judgement depending on the needs of the patient.

True

What are the two levels of HPI

Brief (1-3 elements) and extended(4 or more elements)

The problem-focused and expanded problem-focused levels of history contain a brief review of the problems surrounding why the patient is being seen that day.

True

The detailed and comprehensive levels of history contain an extended review of the HPI elements.

True

An inventory of the body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced.

Review of Systems

A review of the patient's past experience with illnesses, injuries, and treatment .

Past History

A review of medical events in the patient's family

Family History

An age appropriate review of past and current activities

Social History

is a review that is focused on the organ system involved in the chief complaint

Problem pertinent ROS

Includes a review of the system directly involved in the chief complaint, plus related (up to nine) systems.

Extended ROS

Includes at least 10 of the 14 Organ Systems

Complete ROS

is a review of the pas, family,and social history of the patient

PFSH

What are the two levels of PFSH?

pertinent and complete

What are the four levels of history?

problem focused, expanded problem focused, detailed, and comprehensive

When the physician focuses on the CC and a brief history of the present problem of a patient.

Problem focused

When the physician focuses on a CC, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.

Expanded problem focused

When the physician focuses on a CC and obtains an extended history of the present problem.

Detailed

When the physician documents the CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH

Comprehensive

Is the subjective information the patient provides the physician

History

Objective information that the physician gathers.

Examination

Head (Including face)

Body Area

Neck

Body Area

Chest (Including Breast and axillae)

Body area

Abdomen

Body Area

Genitalia, groin,and buttocks

Body Area

Back

Body Area

Each extremity

Body Area

Ophthalmologic (eyes)

Organ System

Otolaryngologic (ears,nose,mouth, and throat)

Organ System

Cardiovascular

Organ System

Respiratory

Organ System

Gastrointestinal

Organ System

Genitourinary

Organ System

Muscoskeletal

Organ System

Integumentary (Skin)

Organ System

Neurologic

Organ System

Psychiatric

Organ System

Hematologic/ Lymphatic/ Immunologic

Organ System

What are the four levels of examination?

Problem focused,expanded problem focused, detailed, and comprehensive

Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA

Problem Focused

A limited examination of the affected area BA or OS and other related BAs or OSs. It involves a limited examination of 2-7 BAs or OSs

Expanded problem focused

An extended examination of the affected BAs or related OSs. It involves an extended examination of 2-7 BAs or OSs

Detailed

Encompasses at least 8 OSs without counting BAs

Comprehensive

The levels of examination include both body areas (BA) and organ systems (OS), with the exception of the comprehensive examination.

True or False

When abstracting a medical record count both the

BAs and OSs`

Constitutional on the exam count as 1 OS and that OS counts when calculating the examination.

True or False?

the key component of MDM is based on the__________ of the decision the physician must make regarding the patient's diagnosis and care.

complexity

Complexity of decision making is based on three elements.

True or False?

What are the three elements of decision making?

number of diagnoses or management options, Amount and/or complexity of data to review, and risk of complication and/or death if the condition goes untreated.

What are the four types of MDM complexity?

straightforward, low, moderate,and high

Blood pressure, sitting

Constitutional(OS)

Blood pressure, lying

Constitutional(OS)

Pulse

Constitutional(OS)

Respiration

Constitutional(OS)

Temperature

Constitutional(OS)

Height

Constitutional(OS)

Weight

Constitutional(OS)

General appearance

Constitutional(OS)

Minimal diagnosis and/or management options, minimal or none for the amount and complexity of data to be reviewed,and minimal risks to the patient of complications or death if untreated.

Straightforward

Limited number of diagnosis and/or management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated

low complexity

multiple diagnosis and or management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.

moderate complexity

extensive diagnosis and or management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.

high complexity

____________ factors are those conditions that help the physician to determine the extent of history, examination, and decision making necessary to treat the patient

Contributory

What are the three contributory factors?

counseling, coordination of care, and the nature of the presenting problem.

Involves discussion of diagnostic results, impressions, and recommended diagnostic studies; prognosis; risks and benefits of treatment;instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education.

Counseling

A physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long- term nursing facility.

Coordination of care

a disease, conditon, illness, injury, symptom, sign finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter

Presenting problem

How many types of presenting problems are there?

five

What are the five types of presenting problems?

Minimal, Self-limited, low severity, and moderate severity

A _______ problem is a blood pressure reading, a dressing change,or another service that can be performed without the physician being immediately present.

Minimal

also called a minor presenting problem

self-limited

The risk of complete sickness without treatment is low, there is no risk of death without treatment, and full recovery without impairment is expected.

low severity

the risk of complete sickness without treatment is moderate, there is moderate risk of death without treatment and an uncertain prognosis or increased probability of impairment exists,

moderate severity

The risk of complete sickness without treatment is high to extreme, there is a moderate to high risk of death without treatment, or there is a strong probability of severe, prolonged functional impairment.

High severity

What are two measurements of time?

Face-to-face time and unit/floor time

_________ time is the time a physician spends directly with a patient during an office visit obtaining the history, performing an examination, and discussing results.

Face-to-Face time

Inpatient time is measured as ________ time and is used to describe the time a physician spends in the hospital setting dealing with the patient's care.

unit/floor time

_______ services are based on time

Discharge

More than one physician can use the subsequent care codes on the same day. This is called

Concurrent Care

Who maintains the primary responsibility for the overall care of the patient,no matter how many other physicians are providing services to the patient, unless a formal transfer of care has occurred.

attending physician

These codes are reported for either inpatients or outpatients who are admitted and discharged on the same day.

Observation or Inpatient Care Services (99234-99236)

______________ are reported on the final day of services for a multiple-day-stay in a hospital setting.

Inpatient Hospital Discharge Services

Findings that were not the reason for the test.

Incidental findings

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