Question 1

Match each term with the correct statement below.
-quality

Accepted Answer

A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath 
A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath

Question 2

The HPI must be documented in the medical record by:

Accepted Answer

A) the physician 
B) any office staff member 
C) the patient 
D) any of the above 
A) the physician 
B) any office staff member 
C) the patient 
D) any of the above

Question 3

Match the following examination types to the correct examination description.
-detailed

Accepted Answer

A) The most extensive examination that encompasses a complete single specialty examination or complete multisystem examination 
B) Examination limited to the affected body area or organ system and other related organ systems. 
C) Examination limited to the affected body area or organ system identified by the chief complaint 
D) An extended examination of the affected body area or areas and related organ system(s) 
A) The most extensive examination that encompasses a complete single specialty examination or complete multisystem examination 
B) Examination limited to the affected body area or organ system and other related organ systems. 
C) Examination limited to the affected body area or organ system identified by the chief complaint 
D) An extended examination of the affected body area or areas and related organ system(s)

Question 4

Match each term with the correct statement below.
-severity

Accepted Answer

A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath 
A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath

Question 5

Identify as body (BA) or organ system (OS): neck

Accepted Answer

A) BA 
B) OS 
A) BA 
B) OS

Question 6

CHART NOTE
CC: Dizziness
SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness.She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day.Her last TSH was last year and the level appeared to be normal at 0.49.
OBJECTIVE: The patient appears to be in good health and in good spirits.Her BP is 120/81.Afebrile.HEENT normal.Neck is supple.No palpable masses are noted.No thyromegaly, tenderness, or nodes.TSA is elevated at 9.9.
ASSESSMENT: Hypothyroidism (MDM was low).
PLAN: Increase Synthroid to 0.15 mg q day.Recheck in 2 months.
CPT Code: ____________________

Accepted Answer

The answer of CHART NOTE
CC: Dizziness
SUBJECTIVE: This 46-year-old female established...

Question 7

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

A) straightforward 
B) low 
C) moderate 
D) high 
A) straightforward 
B) low 
C) moderate 
D) high

Question 8

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

A) skilled nursing facility 
B) intermediate care facility 
C) long-term care facility 
D) all of the above 
A) skilled nursing facility 
B) intermediate care facility 
C) long-term care facility 
D) all of the above

Question 9

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

Accepted Answer

A) a skilled nursing facility 
B) a temporary care unit 
C) an acute care facility 
D) a hospital observation unit 
A) a skilled nursing facility 
B) a temporary care unit 
C) an acute care facility 
D) a hospital observation unit

Question 10

Location: Hospital
PROGRESS NOTE
The patient is seen today.She has been transferred from the ICU to the floor.She has essentially stabilized.Again, she is having some type of seizure activity.
PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized.Her postoperative dressings are in place.She did have a significantly elevated INR so
the dressings have been kept in place to minimize the risk of bleeding.She was sleeping when I saw her so I did not wake her.Her toes are pink and warm.Calves are soft.
IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
PLAN: I will continue to follow.From my standpoint, she can mobilize and weight bear as tolerated on the left side.We will change her dressings and place TED hose on the left.We will continue to follow her INR and hemoglobin.Of note, she has been made code status II.
CPT Code: ____________________

Accepted Answer

The answer of Location: Hospital
PROGRESS NOTE
The patient is seen today.She...

Question 11

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

Accepted Answer

A) 28 days or younger 
B) less than 7 days 
C) less than 20 days 
D) none of the above 
A) 28 days or younger 
B) less than 7 days 
C) less than 20 days 
D) none of the above

Question 12

The _______________ is a statement describing the reason for the encounter and is a history element.

Accepted Answer

The answer of The _______________ is a statement describing the...

Question 13

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

Accepted Answer

A) Inpatient Neonatal and Pediatric Critical Care 
B) Pediatric Critical Care Patient Transport 
C) Initial and Continuing Intensive Care Services 
D) Complex Chronic Care Management Services 
A) Inpatient Neonatal and Pediatric Critical Care 
B) Pediatric Critical Care Patient Transport 
C) Initial and Continuing Intensive Care Services 
D) Complex Chronic Care Management Services

Question 14

Select the three factors that the coder must consider in the assignment.

Accepted Answer

A) place of service 
B) patient status 
C) patient history 
D) type of service 
E) level of service 
A) place of service 
B) patient status 
C) patient history 
D) type of service 
E) level of service

Question 15

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

Accepted Answer

A) number of diagnoses 
B) risk of morbidity 
C) amount of data 
D) all of the above 
A) number of diagnoses 
B) risk of morbidity 
C) amount of data 
D) all of the above

Question 16

Match each term with the correct statement below.
-location

Accepted Answer

A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath 
A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath

Question 17

Select the four elements of history.

Accepted Answer

A) review of systems (ROS) 
B) history of present illness (HPI) 
C) past, family, and social history (PSFH) 
D) organ systems (OS) 
E) medical decision making (MDM)
F)chief complaint (C
C) 
G)body areas (B
A)  
A) review of systems (ROS) 
B) history of present illness (HPI) 
C) past, family, and social history (PSFH) 
D) organ systems (OS) 
E) medical decision making (MDM)
F)chief complaint (C
C) 
G)body areas (B
A)

Question 18

Select the four types of patient status.

Accepted Answer

A) inpatient 
B) home patient 
C) existing 
D) new 
E) outpatient
F)newborn
G)established 
A) inpatient 
B) home patient 
C) existing 
D) new 
E) outpatient
F)newborn
G)established

Question 19

CHART NOTE
CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration.
OBJECTIVE: This is a 50-year-old male in apparent good health.His BP is 119/78.Rectal examination showed a grade 1 hemorrhoid in the 2 o'clock position approximately 2 cm across.The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.
ASSESSMENT: Hemorrhoid.
PLAN: Discussed conservative treatment options with the patient and explained surgical option.He wants to try the more conservative approach of stool softeners, warm and sitz baths.I discussed with him the importance of improved bowel habits.He is to return for a recheck in 2 months.The medical decision making was of straightforward complexity.
CPT Code: ____________________

Accepted Answer

The answer of CHART NOTE
CC: This established patient presents to...

Question 20

Match each term with the correct statement below.
-timing

Accepted Answer

A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath 
A) worst I've ever had 
B) continuous 
C) chest 
D) some relief with rest 
E) on exertion
F)tightness
G)since last night
H)some shortness of breath

Exam 11: Evaluation and Management EM Services

Match each term with the correct statement below. -quality

The HPI must be documented in the medical record by:

Match the following examination types to the correct examination description. -detailed

Match each term with the correct statement below. -severity

Identify as body (BA) or organ system (OS): neck

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?

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

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

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

The _______________ is a statement describing the reason for the encounter and is a history element.

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

Select the three factors that the coder must consider in the assignment.

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

Match each term with the correct statement below. -location

Select the four elements of history.

Select the four types of patient status.

Match each term with the correct statement below. -timing

Reimbursement, Hipaa, and Compliance

An Overview of ICD-10-CM

ICD-10-CM Outpatient Coding and Reporting Guidelines

Using ICD-10-CM

Chapter-Specific Guidelines ICD-10-CM Chapters 1-10

Chapter-Specific Guidelines ICD-10-CM Chapters 11-14

Chapter-Specific Guidelines ICD-10-CM Chapters 15-21

Introduction to CPT

Introduction to Level Ii National Codes Hcpcs

Modifiers

Anesthesia

Surgery Guidelines and General Surgery

Integumentary System

Musculoskeletal System

Respiratory System

Cardiovascular System

Hemic, Lymphatic, Mediastinum, and Diaphragm

Digestive System

Urinary and Male Genital Systems

Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery

Endocrine and Nervous Systems

Eye, Ocular Adnexa, Auditory, and Operating Microscope

Radiology

Pathologylaboratory

Medicine

Inpatient Coding

Filters