Audio: Documenting & Coding E/M Encounters



Audio: Documenting & Coding E/M Encounters

Presented by: Jacqueline Thelian, CPC, CPC-I

Question and Answers

1) When were the first E/M guidelines implemented?

a) 1990

b) 1992

c) 1995

d) 1997

2) When comparing the 1995 and 1997 guidelines which of the three key components are the same in each guideline?

a) Medical Decision Making

b) History

c) Physical Exam

d) None of the above

3) True or false. The definition of a new patient has been changed in the 2012 CPT manual and the E/M guidelines.

a) True

b) False

4) Using the 1995 guidelines, how many elements in the body system/organ system (one or more in details) must be documented in order to code a 99203/99243 visit?

a) 2-4

b) 5-7

c) 8 or more

d) 2-9

5) When the patient mentions something that makes the associated symptom/s (in relation to the presenting problem) feel better, the physician can document that under which of the following elements of the HPI?

a) Location

b) Timing

c) Context

d) Modifying factors

6) True or false. The ROS and/or PFSH can only be recorded by the ancillary staff and requires a full notation by the physician to confirm this information.

a) True

b) False

7) When using the 1995 guidelines to select a level of service for an established patient a certain amount of elements must be met. What is that amount of elements?

a) 2 out of 3 elements

b) 2 out of 4 elements

c) 3 out of 3 elements

d) 4 out of 4 elements

8) Which of the following does not have a specific specialty examination under the 1997 guidelines but instead uses the General Multi-system examination?

a) Genitourinary

b) Skin

c) Ob-Gyn

d) Ear, Nose and Throat

9) Look at the 1997 Content and Documentation Requirements for the Genitourinary specialty specific physical examination. How many elements in a shaded box must be documented to support a comprehensive examination?

a) One to five elements

b) At least six elements

c) At least twelve elements

d) Every elements

10) Two of the specialty specific examinations under the 1997 guidelines have caveats/notes that provide further clarification on the differences between Comprehensive examination and the three lower levels. Which of the following are those two examinations?

a) Hematologic/Lymphatic/Immunologic and Ear, Nose and Throat

b) Musculoskeletal and Skin

c) Skin and Psychiatric

d) Neurological and Musculoskeletal

11) When deciding on a level of Decision Making, diagnostic or management options are one of the three elements that could be considered. Which of the following is not an example of a diagnostic or management option?

a) The initiation of changes in treatment

b) Problem without an established diagnosis

c) Documentation of any referrals or consults

d) The review of lab, radiology and or other diagnostic tests

12) According to the Table of Risk (slide 66), what is the level of risk that corresponds to the presenting problem of “Acute complicated injury, e.g. head injury with brief loss of consciousness”?

a) Minimal

b) Low

c) Moderate

d) High

13) According to the Table of Risk (slide 66), if you have a limited number of diagnoses or management options and a low risk of complications and/or morbidity or mortality, what is the type of medical decision making that would be selected?

a) Straightforward

b) Low complexity

c) Moderate complexity

d) High complexity

14) When using time to determine the level of service, a certain percentage of face-to-face time must be used in the counseling and/or coordination of care. Which of the following examples of percentages would not qualify to be able to use as the determining factor?

a) 25% of the total encounter used in the counseling and/or coordination of time

b) 50% of the total encounter used in the counseling and/or coordination of time

c) 55% of the total encounter used in the counseling and/or coordination of time

d) 75% of the total encounter used in the counseling and/or coordination of time

15) Under the 1995 Guidelines – Established Outpatient Visit, what is the level of service that requires 15 minutes of time to be documented in order to code it?

a) 99201

b) 99212

c) 99203

d) 99213

16) What are the three “R’s” of consultations?

a) Read, Refer, Report

b) Refer, Render, Report

c) Request, Render, Report

d) Request, Render, Refer

17) What was the date that consultation codes were no longer recognized by Medicare?

a) January 1, 2010

b) October 1, 2010

c) January 1, 2011

d) October 1, 2011

18) What is the modifier that is appended to the initial visit code by the principle physician of record (the admitting or attending physician overseeing the patient care)?

a) 25

b) AI

c) 77

d) P6

19) True or false. Emergency department codes do not distinguish between new or established patients.

a) True

b) False

20) When using discharge management codes 99238 and 99239, should time be documented in the discharge notes?

a) No

b) Yes, but only when the time is 30 minutes or less

c) Yes, only when the time is greater or equal to 30 minutes

d) Yes, as both codes are time-based codes.

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