20 terms

CPT Coding Week 3

Chapter 15 Step By Step Medical Coding By: Carol J Buck
Is examination of the back an organ system or body area examination?
Body Area
What are the four types of patient status?
New, Established, Outpatient and Inpatient
The first outpatient visit is called the ________ visit, and the second visit is called the ________ visit.
Initial, subsequent
The first three factors a coder must consider when coding are patient? .
Patient status, type of service, place of service
How many types of histories are there?
Which history is more complex: the problem focused history or the expanded problem focused history?
Expaneded Problem Focused
List the four types of examinations, in order of difficulty from least difficult to most difficult.
Problem focused, expanded problem focused, detailed, and comprehensive
The examination that is limited to the affected body area is the ________.
Problem Focused
What does VLBW stand for?
Very Low Birth Weight
What medical decision making involves a situation in which the diagnosis and management options are minimal, data amount and complexity that must be reviewed are minimal/none, and there is a minimal risk to the patient of complications or death?
What term is used to describe a patient who has been formally admitted to a hospital?
The physician provides initial intensive care service for the evaluation and management of a critically ill newborn (5 days old) inpatient for one day.
CPT Code: ________.
A 55-year-old man is seen by the dermatologist for the first time and complains of two cystic lesions on his back. Considering that the patient is otherwise healthy and has a primary care physician caring for him, the dermatologist focuses the history of the present illness on the skin lesions (problem focused history) and focuses the problem focused physical examination on the patient's trunk. The physician concludes with straightforward decision making that the lesions are sebaceous cysts. The physician advises the patient that the lesions should be monitored for any changes, but that no surgical intervention is warranted at this time.
CPT Code: ________.
A 68-year-old woman visits her internist again complaining of angina that seems to have worsened over the past 3 days. The patient had had an acute anterior wall myocardial infarction (MI) 2 months earlier. One month after the acute MI, she began to have angina pectoris. The patient also states that she thinks the medications are causing her to have gastrointestinal problems while not relieving her symptoms. She had refused a cardiac catheterization after her MI to evaluate the extent of her coronary artery disease. The physician performs a detailed history and a detailed physical examination of her cardiovascular, respiratory, and gastrointestinal systems. The physician indicates that the decision making process is moderately complex, given the number of conditions it is necessary to consider.
CPT Code: ________.
A 22-year-old woman visits the gynecologist for the first time since relocating from another state last year. The patient wants a gynecologic examination and wants to discuss contraceptive options with the physician (think Preventive Medicine Services!). The physician collects pertinent past and social history related to the patient's reproductive system and performs a pertinent systems review extended to a limited number of additional systems. The physician completes the history with an extended history of her present physical state. A physical examination includes her cardiovascular and respiratory systems with an extended review of her genitourinary system. Given the patient's history of not tolerating certain types of oral contraceptives in the past, the physician's decision making involves a limited number of management options, all with low risk of morbidity to the patient.
CPT Code: ________.
An established patient is admitted on observation status for influenza symptoms and extreme nausea and vomiting. The patient is severely dehydrated and has been experiencing dizziness and mental confusion for the past 2 days. Prior to this episode the patient was well but became acutely ill overnight with these symptoms. Given the abrupt onset of these symptoms, the physician has to consider multiple possible causes and orders a variety of laboratory tests to be performed. The patient is at risk for a moderate number of complications. The MDM complexity is moderate. A comprehensive history is collected, and a comprehensive head-to-toe physical examination is performed.

CPT Code: ________.
A physician visits another patient on observation status who has severe influenza. The decision is made to admit the patient, whose condition has worsened and who is not responding to the therapy initiated on the observation unit. The physician performs a detailed history and a detailed physical examination to reflect the patient's current status. The patient's problem is of low severity but requires ongoing active management, with possible surgical consultation. The MDM complexity is low.
CPT Code: ________.
An 8-month-old infant, who is a new patient, is brought in by her mother for diaper rash. The physician focuses on the problem of the diaper rash for the problem focused history and examination. The MDM complexity is straightforward.
CPT Code: ________.
A 33-year-old man is brought to his private physician's office by his wife. The man, who is an established patient, has been experiencing severe leg pain of 2 weeks' duration. In the past 2 days, the patient has experienced fainting spells, nausea, and vomiting. The patient has had multiple other vague complaints over the past month that he dismissed as unimportant, but his wife is not so sure, and she describes his general health as deteriorating. The physician performs a comprehensive multisystem physical examination after performing a complete review of systems and a complete past medical, family, and social history, with an extended history of the present illness (comprehensive history). The physician has to consider an extensive number of diagnoses, orders a variety of tests to be performed immediately, and indicates the MDM complexity to be high.
CPT Code: ________.
A 42-year-old woman, who is an established patient, visits her family practitioner with the chief complaint of a self-discovered breast lump. She describes a feeling of fullness and tenderness over the mass that has become more pronounced in the past 2 weeks. Because the patient is otherwise healthy and has had a physical within the past 6 months, the physician focuses his attention on the breast lump during the taking of a problem focused history and the performance of a problem focused physical examination. The physician orders an immediate mammography to be performed and a follow-up appointment in 5 days. The physician has given the patient no other options and indicates that the MDM complexity is straightforward.
CPT Code: ________