Question 1

When time is reported using CPT codes, it documents the exact amount of time a physician spends with a patient.

Accepted Answer

CPT codes primarily describe the type of service provided rather than documenting the exact amount of time a physician spends with a patient. Some codes do factor in time as part of the criteria, but not all do.

Question 2

The two-digit code placed after the main CPT code to indicate that the description of the service or procedure has been altered is a(n) __________ .

Accepted Answer

The answer of The two-digit code placed after the main...

Question 3

A history that involves the chief complaint (CC) and a brief history of present illness (HPI) is a(n) __________ history.

Accepted Answer

The answer of A history that involves the chief complaint...

Question 4

A discussion with the patient and/or a family member to discuss risk-factor reduction is considered __________ .

Accepted Answer

The answer of A discussion with the patient and/or a...

Question 5

A patient who has received professional services from the physician or a physician in the same group within the past 3 years is referred to as a(n) __________ patient.

Accepted Answer

The answer of A patient who has received professional services...

Question 6

An inventory of the body obtained when the physician asks the patient a series of questions to identify signs of illness and/or symptoms the patient may be experiencing is called a(n) __________ .

Accepted Answer

The answer of An inventory of the body obtained when...

Question 7

A description of the level of symptoms or pain or their ranking on a scale is the level of __________ .

Accepted Answer

The answer of A description of the level of symptoms...

Question 8

A review of a patient's past experiences with illnesses, injuries, and treatments is called a social history.

Accepted Answer

A review of a patient's past experiences with illnesses, injuries, and treatments is called a medical history, not a social history. A social history typically includes information about a person's lifestyle, habits, and social environment.

Question 9

The section containing evaluation and management (E/M) codes is at the front of the code book because it is frequently used. E/M codes are used to report a significant portion of physician services.

Accepted Answer

The statement is true. The E/M codes section is located at the front of the CPT code book because it is commonly used to report physician services. E/M codes are used to report services such as office visits, consultations, emergency department visits, and hospital visits.

Question 10

The risk of significant complications, morbidity, and/or mortality is a factor in determining the level of medical decision making (MDM).

Accepted Answer

The risk of significant complications, morbidity, and/or mortality is one of the three key components used to determine the level of medical decision making (MDM) in the evaluation and management (E/M) coding system. The other two components are the complexity of establishing the diagnosis and the data reviewed and analyzed. The higher the risk of complications or adverse outcomes, the higher the level of MDM required to manage the patient's care.

Question 11

A description of other things that happen when the symptom or pain occurs is referred to as a "modifying factor."

Accepted Answer

The answer of A description of other things that happen...

Question 12

No distinction is made between new and established patients in coding for emergency room care.

Accepted Answer

Emergency room coding does not differentiate between new and established patients. The codes used for evaluation and management are determined by the level of service provided, not the patient's status.

Question 13

A review of the patient's prior experience with illnesses, injuries, and treatments is the __________ .

Accepted Answer

The answer of A review of the patient's prior experience...

Question 14

A comprehensive exam would include a general multisystem exam or a complete exam of a single organ system.

Accepted Answer

A comprehensive exam typically includes a general multisystem exam, which assesses multiple organ systems in the body. However, it may also include a complete exam of a single organ system if specific concerns or symptoms warrant it.

Question 15

The transfer of the total care or a portion of care of a patient from one physician to another is a(n) __________ .

Accepted Answer

The answer of The transfer of the total care or...

Question 16

The set of temporary codes used for emerging technology, services, and procedures is known as __________ CPT.

Accepted Answer

The answer of The set of temporary codes used for...

Question 17

A physician providing a consultation must document his or her opinion in the medical record and render the opinion in writing to the requesting physician.

Accepted Answer

This is a requirement in medical practice and is considered part of professional courtesy and ethical behavior. It helps to ensure that patients receive appropriate care and that medical professionals collaborate effectively in their diagnoses and treatments.

Question 18

When an evaluation and management (E/M) code is assigned, the patient's medical record must contain the clinical data to support it.

Accepted Answer

This is because E/M codes are based on documentation of the patient's medical history, examination, and medical decision-making, and must be supported by clinical data in the medical record. Without adequate documentation, it is not appropriate to assign an E/M code.

Question 19

An established patient is defined as one who has received professional service from the physician or another physician of the same specialty in the same group within the last 2 years.

Accepted Answer

An established patient is defined as one who has received professional services from the physician or another physician of the same specialty in the same group within the last 3 years, not 2 years.

Question 20

A concise statement, usually stated in the patient's words, describing the symptom, problem, or condition is called the __________ .

Accepted Answer

The answer of A concise statement, usually stated in the...

Quiz 7: Introduction to Cpt and Place of Service Coding