Question 1

In the E/M section, an 8 in the fourth place identifies:

Accepted Answer

An 8 in the fourth place identifies an emergency service.

Question 2

Hospital Observation Services codes describe examinations provided in:

Accepted Answer

Hospital Observation Services codes are specifically used for examinations provided in a designated observation status room in a hospital. These services are for patients who are not admitted as inpatients but require a significant period of observation.

Question 3

Services provided to a patient in order to maintain health and prevent disease are called:

Accepted Answer

Preventive services are designed to help people stay healthy and to prevent diseases from occurring, by offering screenings, check-ups, and patient counseling to prevent health problems.

Question 4

Past, family, and social history (PFSH) encompasses which of the following:

Accepted Answer

Past, family, and social history (PFSH) includes information about the patient's past medical and surgical history, allergies, and illnesses in the family, but does not typically include details about the spouse's risk factors or marital status.

Question 5

In the E/M section, a 2 in the fourth place identifies:

Accepted Answer

The answer of In the E/M section, a 2 in...

Question 6

Code 99217 describes:

Accepted Answer

Code 99217 is used for Observation Care Discharge Services.

Question 7

To select the appropriate code from this section:

Accepted Answer

The coder's role involves abstracting necessary information from the provider's documentation to assign the correct codes for billing and record-keeping purposes.

Question 8

All of the following are categories included in the E/M section of the CPT manual except:

Accepted Answer

Psychiatric services are not a category in the Evaluation and Management (E/M) section of the CPT manual; they are typically found in the Psychiatry section.

Question 9

A consultation service in the hospital is represented by a _____ fourth digit:

Accepted Answer

The answer of A consultation service in the hospital is...

Question 10

In the Exam component, organ system element, a detailed exam is made up of _______ body areas and/or organ systems:

Accepted Answer

A detailed exam in the Exam component, organ system element, typically involves 5-7 body areas and/or organ systems. This level of examination is more comprehensive than a problem-focused or expanded problem-focused exam but less comprehensive than a comprehensive exam, which would involve 8 or more body areas or organ systems.

Question 11

The major factor for using the consultation range of codes is the ____________ of the service:

Accepted Answer

The major factor for using the consultation range of codes is the intent of the service, as it reflects the purpose behind seeking or providing a consultation, which is to seek advice or an opinion regarding evaluation or management options for a specific problem.

Question 12

The only code in the 99211-99215 range that does not need to meet key component requirements is:

Accepted Answer

99211 is the only code in the 99211-99215 range that does not require the documentation of the key components (history, examination, and medical decision making) because it represents a minimal service, such as a blood pressure check.

Question 13

In the E/M section, a 4 in the fourth place identifies:

Accepted Answer

The answer of In the E/M section, a 4 in...

Question 14

The description of the illness or injury which precipitated the present encounter is the:

Accepted Answer

The history of present illness (HPI) is the description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present. It includes the patient's experience with the illness, such as the nature of the symptoms, their location, quality, severity, timing, context, the factors that aggravate or relieve the symptoms, and associated manifestations.

Question 15

It is required that _____ key component(s) are met when selecting a code from 99201-99205:

Accepted Answer

When selecting a code from 99201-99205, three key components must be met: history, examination, and medical decision making.

Question 16

A patient presents to the provider's office with swelling of the face and hands after beginning an amoxicillin treatment three days ago. The patient has no current known drug allergies; the physician requests in writing that an allergist evaluate the patient, render an opinion, and supply a written report stating the opinion. This is an example of a(n):

Accepted Answer

This is an example of a consultation, where a physician requests the expertise of another physician (in this case, an allergist) to evaluate a patient and provide a written opinion or advice on the patient's condition.

Question 17

Select the statement that is not true regarding critical care code selection:

Accepted Answer

Time spent outside the unit is generally not considered in the time documentation for critical care codes.

Question 18

The _______ documentation guidelines are followed for the CPC exam:

Accepted Answer

The 1995 documentation guidelines are followed for the CPC exam.

Question 19

If a patient is discharged from inpatient care on the same day as a nursing facility admit, the coder may select:

Accepted Answer

When a patient is discharged from inpatient care and admitted to a nursing facility on the same day, both a hospital discharge code and an Initial Nursing Facility Care code should be used to accurately reflect the transition of care.

Question 20

Select the statement that is not true regarding code 99217, Observation Care Discharge Services:

Accepted Answer

Code 99217 is used specifically for Observation Care Discharge Services and cannot be reported with an inpatient initial service because it is designated for patients in observation status, not those who have been admitted as inpatients.

Quiz 5: Evaluation and Management