Question 1

According to E/M guidelines, a(n) ____ exam encompasses a complete single-specialty exam or a complete multisystem exam.

Accepted Answer

A comprehensive exam is the only type of exam that encompasses a complete single-specialty exam or a complete multisystem exam, according to E/M guidelines.

Question 2

The level of E/M service is based on:

Accepted Answer

The level of E/M service is determined by a combination of factors including documentation, key components (such as history, exam, and medical decision making), and contributing factors (such as the amount of time spent by the provider). Therefore, all of the listed options are important factors in determining the appropriate level of E/M service.

Question 3

The term used to describe a patient who has NOT been formally admitted to a health care facility is ____________________.

Accepted Answer

outpatient

Question 4

An established patient is one who has received professional service from the physician or another physician of the exact same specialty and subspecialty in the same group within the past ____________________ years.

Accepted Answer

The answer of An established patient is one who has...

Question 5

The request for advice or opinion from one physician to another physician is this type of service:

Accepted Answer

Consultation is the type of service that involves a request for advice or opinion from one physician to another physician. Counseling involves discussing treatment options or providing emotional support to a patient. Concurrent care involves multiple healthcare providers working together to treat a patient. Coordination of care involves managing and integrating multiple aspects of a patient's healthcare.

Question 6

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?

Accepted Answer

An extended exam of the affected body areas and related organ systems corresponds to a detailed level of examination.

Question 7

Bruising would be an element of review of this organ system.

Accepted Answer

The answer of Bruising would be an element of review...

Question 8

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history?

Accepted Answer

The level of history is determined by the extent of the HPI, ROS, and PFSH. An extended HPI, extended ROS, and pertinent PFSH correspond to a detailed history.

Question 9

When a physician performs a preventive care service, the extent of the exam is determined by the:

Accepted Answer

The answer of When a physician performs a preventive care...

Question 10

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?

Accepted Answer

CPT code 99284 is used for emergency department (ED) visits that require a detailed examination and medical decision-making of moderate complexity. This code is appropriate when the provider spends at least 30 minutes examining and treating the patient.

Question 11

The HPI must be documented in the medical record by:

Accepted Answer

The HPI must be documented by the physician, as they are the one responsible for conducting the examination and diagnosing the patient's condition. The other options may assist in gathering information for the HPI, but only the physician can accurately document it in the medical record.

Question 12

The definition of low birth weight can be found in the notes for subheading ______________________________.

Accepted Answer

The answer of The definition of low birth weight can...

Question 13

Medical decision making (MDM) is based on the ____ the physician must consider about the management of a patient's condition.

Accepted Answer

Medical decision making (MDM) is a complex process that takes into account various factors such as the number of diagnoses, risk of morbidity, amount of data, and more. Therefore, all of the above options are crucial to consider in making an informed and effective decision about the management of a patient's condition.

Question 14

According to information in 99468, what is the age of a neonate?

Accepted Answer

A neonate is defined as a newborn child, specifically one that is 28 days old or younger.

Question 15

Critical care codes are reported based on:

Accepted Answer

Critical care codes are reported based on time spent providing critical care to the patient. The specific time thresholds for reporting critical care codes vary depending on the patient's age and the setting in which the care is provided. The other options listed (A, C, and D) are not relevant to reporting critical care codes.

Question 16

The examination is the ____ portion of the E/M service.

Accepted Answer

The examination is the objective portion of the E/M service, as it involves the physician's objective evaluation of the patient's physical condition. The subjective portion (A) is the patient's account of their symptoms and medical history, while the assessment (C) and plan (D) are the physician's medical decision-making based on their evaluation of the patient.

Question 17

Codes from the E/M subsection Nursing Facilities Service are used to report services provided in nursing facilities that used to be known as:

Accepted Answer

The E/M subsection Nursing Facilities Service is used to report services provided in nursing facilities, which is an umbrella term that includes skilled nursing facilities, intermediate care facilities, and long-term care facilities. Therefore, the best choice is D, all of the above.

Question 18

These elements would be part of the ____ history: employment, education, use of drugs.

Accepted Answer

The social history of a person includes aspects like employment, education, and use of drugs, as these relate to their lifestyle and social environment.

Question 19

The Hospital Inpatient Services subsection is used for patients admitted to:

Accepted Answer

The Hospital Inpatient Services subsection is specifically intended for patients admitted to an acute care facility. The other options listed are not relevant to this subsection.

Question 20

The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?

Accepted Answer

The level of MDM is moderate, indicating that there are multiple diagnoses and management options to be considered, and the risk of complications or death is moderate. This suggests that a moderate amount of medical decision-making is required.

Quiz 8: Evaluation and Management EM Services