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45 terms

Review 113-1"Evaluation and Managment Services"

STUDY
PLAY
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