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The Next Step- Chapter 1

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