Deck 5: Evaluation and Management

Question 1

Codes for ER visits are grouped into one category and five levels for new/established patients.

Answer 1

True

Question 2

When a consulting physician initiates diagnostic or therapeutic services at the time of service, the encounter is still considered a consultation.

Answer 2

True

Question 3

A patient is seen in her physician's office because of severe migraine and nausea. He has seen her in the recent past for the same condition. Physician decides to admit her to observation, treat her with Demerol and Phenergan, and do some blood work and CT of the head. What codes would be reported?

A) 99213, 99219
B) 99221
C) 99202, 99218
D) 99218

Answer 3

99218

Question 4

Chronological time line of the development of the patient's present illness (problem) from the first sign or symptom to the present time is called ___________________.

A) History of Present Illness
B) History
C) Review of Systems
D) Chief Complaint

Question 5

Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time?

A) Unit time
B) Face to face
C) Incremental
D) Intraservice

Question 6

Time for counseling and coordination of care is not a factor in which circumstance?

A) All answers are correct
B) Neonatal Care
C) ER
D) Preventative Medicine

Question 7

For physician services, they are billed on a 24-hour cycle from midnight to midnight.

Question 8

A consultant cannot initiate diagnostic or therapeutic treatment at the time of the visit.

Question 9

Critical care services are provided only in departments like ICU or CC.

Question 10

In order for a patient to be admitted to observation status, the physician must make sure the patient is placed in an observation area designated by the hospital for no longer than 23 hours.

Question 11

A neonate is defined as newborn through how many days of life?

A) 28
B) 29
C) 30
D) 27

Question 12

Code 99238 is used for a pediatrician to discharge a newborn admitted and discharged on 11/23/11.

Question 13

A patient is admitted from the ER at 11:00 p.m. due to a domestic dispute. Patient leaves the hospital AMA at 3:00 a.m. Exam was comprehensive and history was detailed and medical decision-making was moderate.

A) 99221
B) 99221, 99238
C) 99222
D) 99222, 99238

Question 14

Physicians may choose either set of E/M guidelines to follow per encounter with all their patients.

Question 15

When 50% of the time spent during the office visit is for counseling, select the code based on time and assign a higher-level service.

Question 16

Confirmatory consultations are conducted only in the specialist's office.

Question 17

An internal medicine physician cannot submit a claim for a new patient if the patient was seen for a service by a pulmonologist in the same practice but of a different specialty.

Question 18

Dr. Lewis spent 30 minutes with the patient on the day of discharge observing, providing discharge instructions, examining the patient, and educating the patient on medication. What code would the physician submit for this service?

A) 99238
B) 99239
C) 99217
D) 99219

Question 19

There are a total of 12 elements to be examined or inventoried during the ROS.

Question 20

Three out of three key components must be met or exceeded ____________.

A) with an established patient
B) when the patient is having an initial visit (i.e. Initial hospital)
C) With follow-up inpatient consultation
D) All answers are correct.

Question 21

____________________ is a concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient's words.

Question 22

List key components of evaluation and management services.

Question 23

A 36-year-old patient is seen for a well-check. Patient hasn't been seen in 4 years. During this visit, the physician freezes a wart.

A) 17000
B) 99395, 17000
C) 99385
D) 99385-25, 17000

Question 24

A 42-year-old woman sees her OB/GYN for her regular annual GYN exam. She is healthy and in no distress, and there has been no change since last year's exam. Exam was detailed, history was detailed, and medical decision-making was straightforward.

A) 99386
B) 99202
C) 99214
D) 99396

Question 25

An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a ______________________________.

Question 26

When assigning E/M codes, what four elements must you know or have documented in order to assign the most accurate code level in addition to history, exam, and medical decision-making?

Question 27

Emergency room visit, expanded problem focused history, detailed exam, moderate complexity medical decision-making. Assign the appropriate code(s).

Question 28

Office Visit Date of service: 9/5/11 Last date of treatment: 8/14/07. The patient is seen for a chief complaint of shortness of breath, malaise, and fatigue. The physician performs a detailed history, comprehensive examination, and medical decision-making is of moderate complexity. What is the correct E/M code for this service?

Question 29

Patient is admitted on 10/28/11 at 10:00 a.m. Patient is subsequently discharged at 11:00 p.m. on 10/28/11. Patient insisted on going home. What code is submitted by the physician when a comprehensive history, comprehensive exam, and low decision-making were performed?

Question 30

The four history components are the chief complaint, HPI, ROS, and _________________________.

Question 31

What two criteria must be met in order to assign a consultation code for the consulting physician?