Review 113-1"Evaluation and Managment Services"

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T/F- Findings observed by M.D. about Pt. complaint is known as review of systems:

False

T/F- Patients recieving care in the Neonatal Intensive Care Unit (NICU) of a hospital are typicaly suffering very low birth rate:

True

T/F- Is it acceptable for a M.D. rendering standby care to one hospital Pt. while treating another so long as both Pt's are on the same floor:

False

T\F- Inventory of body systems obtained through questioning to identify signs or symptoms that the Pt. may be experiencing is known as ROS:

True

CPT stands for:

Current Procedure Terminology

Category I CPT codes have ___ digits:

5

Examination is limited to the affected body area or organ system identified by the chief complaint:

Problem focused

M.D. performs a preventive care sevice the extent of the exam is determined by the:

Age of the Pt. and the risk factors identified

Hospital inpatient services subsection is used for Pt's admitted to:

Acute Care

Which CPT appendix would modifiers be found:

Appenix A

Term used to describe a Pt. who has NOT been formally admitted to the health care facility is:

Out Patient

HPI must be documented in the medical record by:

Physician

Examination is the ____ portion of the E/M service:

Objective

Final code selection for determining the level of E/M service is based on:

Key components, Contributary factors

Examination limited to the affected body area or organ system and other related organ systems:

Expanded problem focus

According to CPT guidelines a ___exam encompasses a complete single-specialty exam or a complete multi-system exam:

Comprehensive

Managment of a Pt.'s condition, the M.D.'s level of medical decision making (MDM) is based on:

Overall

The act mandated to adoption of national uniform standards for electronic transmission of financial and administrative health information:

HIPAA

Critical care codes are reported based on:

Time physician spends with a Pt.

Established Pt. is one who has recieved professional service from the M.D. within the ____years:

3- face to face professional service

Codes from the E/M subsection Nursing Facilities Service are used to reprt services provided in this type of facitlity:

Initail , Subsequent, Other Nursing facility or Skilled Intermediate care, Long-term care

The M.D. who had primary responsibility of the Pt. in the hospital is called:

Attending physician

Amniocentesis is:

Puncture of the amniocentesis sac using a needle to withdraw amniotic fluid to be evaluatted and tested

X-ray record of the spinal cord:

Myelogram

Extended exam of the affected body area or areas and related organ systems:

Detailed

BA or OS=> Neck:

BA

BA or OS=> Skin:

OS

BA or OS=> Eyes:

OS

BA or OS=> Back:

BA

BA or OS=> Respiratory:

OS

Spelling->Both sides:

Bilateral

Spelling-> Without oxygen:

Anoxia

Spelling-> Slow heartbeat:

Bradycardia

Spelling-> Lack of water:

Dehydration

Malignant tumor of bone:

Myeloma

For an M.D. to bill CPT code 99213 he is required to document which of the following key components:

A: Expanded problem focused history,
B: Expanded problem focused exam
C: MDM Low complexity

Tachy, as in tachycardia, means:

Swift, fast,abnormal heart action

Endo. as in endoscopy, means:

Within- Visually examine organs, cavity with an endoscope

Domiciliary:

No health services or medical services offered in site, facility includes lodging, meals. supervision, personal care, leisure activities. independently

Concurrent care:

More than one physician provides service to a Pt. on the same day for a different condition

Systemic:

Pertaining to whole body

Preventive medicine services:

Routine physical evaluation and management of a Pt. who is healthy and has no complaints

Observation status:

Classification of a Pt. who does not have an illness severe enough to meet acute inpatient criteria and does not require as intensive as an inpatient but does require hospitalization for a short period of time

Critical care:

Pt. over 24 months of age may either be critically ill or injured, Requires a physician to be constantly available to the Pt. and providing services exclusively to a Pt.

Inpatient status:

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

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