Deck 11: Evaluation and Management EM Services

Question 1

Critical care codes are reported based on:

A)the three key components-history, exam, MDM
B)time
C)amount of documentation
D)procedures performed

Answer 1

time

Question 2

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?

A)problem-focused
B)expanded problem-focused
C)detailed
D)comprehensive

Answer 2

detailed

Question 3

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

A)Integumentary
B)Neurologic
C)Hematologic
D)Immunologic

Answer 3

Hematologic

Question 4

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

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

Question 5

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

A)problem-focused
B)expanded problem-focused
C)detailed
D)comprehensive

Question 6

The level of E/M service is based on:

A)documentation
B)key components
C)contributing factors
D)all of the above

Question 7

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

A)BA
B)OS

Question 8

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

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

Question 9

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

A)past
B)social
C)family
D)any of the above

Question 10

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.

A)2
B)3
C)4
D)5

Question 11

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?

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

Question 12

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

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

Question 13

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

A)problem-focused
B)expanded problem-focused
C)detailed
D)comprehensive

Question 14

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

A)counseling
B)concurrent care
C)coordination of care
D)consultation

Question 15

The HPI must be documented in the medical record by:

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

Question 16

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

A)subjective
B)objective
C)assessment
D)plan

Question 17

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

A)age
B)gender
C)gender and age
D)length of time elapsed since last exam

Question 18

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

A)99284
B)99291
C)99283
D)99220

Question 19

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

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 20

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

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

Question 21

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: ____________________

Question 22

History and exam of the normal newborn infant born in a hospital setting.
CPT Code: ___________________

Question 23

DIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Gloria Baxter
ATTENDING PHYSICIAN: Ronald Green, MD
This patient is continuing on CAPD.Her weight has fluctuated to some extent dependent on some GI losses.She has not been ultrainfiltrating aggressively, but she has not been eating well either.Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate.She did drop her weight to 154, and we have given her some saline boluses through the night.This morning she is reasonably stable.Her weight is 158 pounds.She has no congestive failure and no pain.Her abdomen is soft.Fluid clear.Cultures have remained negative.She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized.
The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient's intolerance to digoxin and/or quinidine.She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response.
The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has.Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep it over 12.This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better.
This illness is still serious.She is not thriving.She is not eating well, and her prognosis at this point is still extremely guarded.Code level II reaffirmed.(MDM is high complexity.)
CPT Code: ____________________

Question 24

A 40-year-old established patient presents to the physician office for a preventive care exam.
CPT Code: ____________________

Question 25

Dr.Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the intensive care unit with acute respiratory distress syndrome.(Separate multiple codes with a comma and then a space in your response.XXXXX, XXXXX)
CPT Codes: _______________________________________ (two codes)

Question 26

An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity.
CPT Code: ____________________

Question 27

A new patient presents to the physician's office at which time the physician provides a comprehensive history and exam with a high complexity MDM.
CPT Code: ____________________

Question 28

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

A)BA
B)OS

Question 29

A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days.A detailed history is then taken.She had associated fever of 101 $\degree$ F yesterday.Mom treated her with Tylenol.The fever this AM is 99 $\degree$
f.She has had some chills and cough as well as some difficulty breathing.No nausea or vomiting.No prior history of otitis.Brother was sick earlier this week.The physician performed a detailed exam of the ENT as well as a limited exam of GI, lungs, and heart.Vital signs were taken in the office.The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic.The MDM is stated to be moderate.
CPT Code: ____________________

Question 30

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

A)BA
B)OS

Question 31

This is a 15-year-old girl, never seen at this clinic.During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.
P/E: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist.Distal neurovascular and tendon exam intact.This is not painful to palpation.(The MDM was of straightforward complexity.)
Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr.Andrews for further treatment.
CPT Code: ____________________

Question 32

CLINIC NOTE
CC: Patient presents for routine examination
SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination.
OBJECTIVE: BP 120/80.Pelvic exam: normal external genitalia.Vagina without discharge except for a scant amount of white discharge that appears normal.Cervix: Multiparous, clear.Bimanual exam is unremarkable.All systems are within normal limits.
ASSESSMENT:
1.Normal BP.
2.Normal pelvic exam.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________

Question 33

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: ____________________

Question 34

This patient is seen in the clinic at the request of Dr.Jones for evaluation of suprapubic pain.Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation.Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago.Pain has become progressively worse.Patient has been seen by Dr.Jones for this pregnancy and has also been seen by Dr.Smith for this current complaint 2 weeks ago.Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge.Labs: CBC and urinalysis performed.Allergies: none.Past medical history: genital wart 1986.Past surgical history: wart removed by laser 1986.Social history: no smoking, illicit drugs, or alcohol.
PE: During an expanded problem-focused examination, the HEENT was found to be normal.FHT: A 148, B 146.Heart: normal.Lungs: CTA.Abdomen: gravid 20 cm.Slight tender suprapubic region.Vaginal exam: closed cervix, thick, long; no discharge.Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1.IUP at 18 weeks with twin gestation.2.Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr.Jones.
CPT Code: ____________________

Question 35

Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today.He had his helmet on as well as all of his racing gear.He actively races motorcycles and has done this all summer long, winning a number of times.He came over a jump and lost control of the bike, going over the handlebars.He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since.He tells me that he was not going fast, approximately 30 mph.He denies any loss of consciousness.The main complaints center only on the left knee and the left elbow.

Question 36

This is a 79-year-old right-handed married female, who I am now hospitalizing for evaluation of recurrent episodes of numbness and weakness of left upper extremity.
This patient relates to having two episodes occurring during the last week of June; both of these occurred while she was eating breakfast around 7:30 AM.She developed sudden onset, without warning, of complete paralysis as well as numbness of the left arm, which lasted for 10 to 15 minutes.There was no speech impairment, no involvement of the face or leg, and no associated headache.These symptoms completely returned to normal.She denies associated chest pain, shortness of breath, or tachycardia with these spells, and there was no jerking of the extremities.About 2 days later, she again had a similar spell.She has not had any further episodes since that time.
Patient's history is significant for hypertension since age 35.She had no previous history of heart disease or diabetes.Two years ago she was seen by Dr.Smith for left putamen hemorrhage.Patient was also found to have right meningioma arising near the petrous region.She describes about 8 episodes over the past 10 years when her right peripheral vision blacked out briefly.She could not recall whether either eye was affected or if this was the right peripheral vision.The last such episode was about 4 months ago.
This past winter she also had about a 2-week period when the right foot seemed to drag.There has been no recent head injury, and there is no prior history of seizures.
Recent carotid Doppler study performed showed moderate calcified plaque in the right carotid bulb but no significant lesion.No flow could be found in the left internal carotid artery, suggesting left internal carotid artery occlusion.Calcified plaque was also noted in the left carotid bulb.Repeat CT scan of the head again showed the old area of infarction involving the left basal ganglia.There was an enhancing lesion starting in the right tentorial region and extending upward into the right parietal area, having the appearance of a meningioma.This is basically unchanged from the previous scan.

CPT Code: ____________________

Question 37

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

A)BA
B)OS

Question 38

CAPD CYCLER DIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Mandy Horton
ATTENDING PHYSICIAN: Ronald Green, MD
This patient was reasonably stable overnight.She was evaluated empty.She was in no cardiorespiratory distress.Clear lungs, dullness at the bases.A few crackles but otherwise a somewhat irregular heart rhythm this morning.Echocardiogram pending.Abdomen soft.Exit site okay.She was going to be put on CAPD today.This is being done to facilitate some of her studies as we can work this around them.CT is planned for this morning.The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there.She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results.We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out.
The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%.(MDM is moderate complexity.)
CPT Code: ____________________

Question 39

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

A)BA
B)OS

Question 40

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

Question 41

The code range for Home Services is ____________________.(Make sure to include a dash with no spaces in your code range.XXXXX-XXXXX)

Question 42

Modifier ____________________ is used to indicate that a separately identifiable E/M service was performed by the same individual on the same day as the preventive medicine service.(Make sure to include a dash in front of your modifier answer.-XX)

Question 43

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: ____________________

Question 44

Match the following examination types to the correct examination description.
comprehensive

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 45

The _______________ (two words) is a statement describing the reason for the encounter and is a history element.

Question 46

Match each term with the correct statement below.
location

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 47

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes.Dr.Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage.The medical decision making is straightforward.
CPT Code: ____________________

Question 48

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

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

Question 49

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

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 50

Match each term with the correct statement below.
duration

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 51

Match each term with the correct statement below.
severity

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 52

Location: Emergency Room
SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling.This patient had right neck lymph node biopsy done 3 days ago.Patient has a dressing in place ever since then.For the past 24 hours, she feels like she has increased swelling and she presents now because of it.She denies any accompanying fever, chills, or sweats.
PAST MEDICAL HISTORY: No known drug allergies.Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy.Medically, she has a history of depression.
REVIEW OF SYSTEMS: Respiratory: She denies dyspnea.
OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress.Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%.HEENT: Conjunctivae and lids normal.Mouth well hydrated.Pharynx normal.Neck is supple.I have removed the dressing.There is a Pen Rose drain in place.The wound seems to be healing well.There is some soft tissue swelling which extends about 3 cm from the wound itself.There is no erythema and no warmth to the area.
ASSESSMENT: Postoperative swelling.
PLAN: I have discussed the case with the ENT surgeon.We have redressed the area.Patient is reassured and will be following up with her doctor tomorrow for drain removal.
CPT Code: ____________________

Question 53

Location: Emergency Room
SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday.She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye.Apparently her eye is opened underneath the bandage and she is unable to close her eyelid.She feels her eyelid is stuck to the bandage.
OBJECTIVE: She is afebrile with stable vital signs.The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this.The Telfa was removed and a wet patch was placed.This did provide significant comfort.Her eye patch was reinforced.
ASSESSMENT: 1.Right corneal abrasion under treatment.2.Eye patch replaced as described above.
PLAN: She has a follow up visit tomorrow morning with ophthalmology.I told her she needs to keep that appointment.She is to return here sooner if she is having increasing problems.
CPT Code: ____________________

Question 54

Match each term with the correct statement below.
timing

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 55

Match the following examination types to the correct examination description.
expanded problem-focused

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 56

Match each term with the correct statement below.
modifying factors

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 57

Match the following examination types to the correct examination description.
problem-focused

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 58

Match each term with the correct statement below.
associated signs and symptoms

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 59

Match each term with the correct statement below.
context

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 60

Match each term with the correct statement below.
quality

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 61

Select the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of service.

A)examination
B)presenting problem
C)medical decision making
D)location
E)history

Question 62

Select the four types of patient status.

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

Question 63

Select the three contributing factors.

A)problem-focused
B)moderate
C)comprehensive
D)straightforward
E)counseling
F)nature of presenting problem
G)expanded problem-focused
H)coordination of care

Question 64

Select the four elements of history.

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 (CC)
G)body areas (BA)

Question 65

Select the four levels of history type.

A)problem-focused
B)moderate
C)comprehensive
D)low
E)Straightforward
F)expanded problem-focused
G)high
H)detailed

Question 66

Select the four levels of medical decision making complexity.

A)problem-focused
B)moderate
C)comprehensive
D)straightforward
E)low
F)expanded problem-focused
G)high
H)detailed

Question 67

Select the three elements that complexity of medical decision making is based on.

A)number of diagnoses or management options
B)patient status
C)amount or complexity of data review
D)risk of complication or death if left untreated
E)chief complaint