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34 terms

Medical Coding 1 CH 2-Review Combo

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Is examination of the back an organ system or body area examination?
BA
4 types of patient status
New, Established, Outpatient and Inpatient
1st outpatient visit is called the ______ visit, and the 2nd visit is called the _______ visit.
Initial, subsequent
First 3 factors a coder must consider when coding are patient ______, ________, and _______
Patient status, type of service, place of service
How many types of histories are there?
4
Which history is more complex; the problem focused history or the expanded problem focused history?
Expanded problem focused
The 4 types of examinations in order of difficulty (least 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
Term used to describe a patient who has been formally admitted to a hospital
Inpatient
Face to face encounter between the physician and patient
Office visit
One who has not received services from the physician or another physician in the same group (and specialty) within the last 3 years
New Patient
Advice or opinion from one physician to another physician
Consultation
One who has been formally admitted to an acute health care facility
Inpatient
One who has received services from the physician or another physician in the same group within the last 3 years.
Established patient
Attention to an acute illness or injury that results in hospitalization
Admission
Evaluation and determination f care for a newborn infant
Newborn care
One who has not been formally admitted to a health care facility
outpatient
4 types of medical decision making, in order of complexity from most to least complex
High, moderate, low, straightforward
Complexity of medical decision making is based on 3 _____
Elements
5 types of presenting problems from the most risk and least recovery to least risk and most recovery
High severity, moderate severity, low severity, self-limited/minor, minimal severity
Counseling and coordination of care are what kind of factors in most cases?
Contributory
Time that is used as a guide for outpatient services is what kind of time?
Face to face or direct
Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time?
Unit/floor
The patients ______ _______ will reflect the number of systems examined by a brief statement of the findings.
Medical record
Discussion with a patient and/or family concerning 1 or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies, prognosis, risks and benefits of treatment is ______
Counseling
The history is the ______ information the patient tells the physician.
Subjective
There is no distinction made between the new and established patients in this service department of a hospital
Emergency
Services rendered by a physician whose opinion or advice is request by another physician or agency in the evaluation and/or treatment of a patient is a _____, whereas the physician who has primary responsibility for the patient in the hospital is called ______
Consultation, attending
When critically ill patients in medical emergencies require the constant attendance of the physician to stabilize them, what kind of care is needed?
Critical care
When care is provided for similar services to the same patient by more than one physician on the same day for different conditions, the care is ______
Concurrent
What is the name for the assumption of the total or specific care of a patient from one physician to another that does no constitute a consultation?
Transfer of care
An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a ____ of _____
Review of systems
If the physician who is standing by does so for 25 minutes, can he or she round the time up to 30 minutes for reporting purposes?
No