Exam 5: Evaluation and Management

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

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

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

____________________ 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.

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

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?

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

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

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.

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.

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?

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

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 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.

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

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

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.

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

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

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?