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COMPREHENSION CHECK 1
1. A cardiologist that specializes in Electrophysiology (EP) covers for a diagnostic cardiologist in the same group. The EP cardiologist sees a patient in the office that is established to the diagnostic cardiologist for the first time. How would the EP cardiologist report her services?
2. According to the E/M guidelines, a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service is a(n)
3. What type of service is provided when a patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the admission and stay?
4. A physician performs and bills a quick strep test on a patient in the office that comes back positive. How is this “counted” in the Data element of MDM?
5. If a physician reads a radiology report and comes to a different conclusion, can that be counted as independent interpretation of a test?
COMPREHENSION CHECK 2
1. A problem with an expected duration of at least one year or until the patient’s death is considered
2. A patient with long-standing hypertension is seen for elevated blood pressure for the past week. Under the MDM Table, what type of problem addressed would this meet?
3. A patient is seen in follow up for a fever and sore throat from a visit two weeks prior. At the previous visit the patient was told to rest and gargle, and the symptoms should resolve in one week. He states that the symptoms are still present and persistent. The physician orders a work-up as the conditions are not resolving. What type of problem is this?
4. A teacher that discusses a patient with a physician is considered a(n)
COMPREHENSION CHECK 2
5. What are the two ways most E/M levels can be selected?
6. The determination of minor or major surgery is based on
7. Long-term intensive monitoring is not performed less than
8. Time is not a descriptive component for
9. When choosing a level of service by time, all the following may be counted toward the time EXCEPT
10. Which of the following would be considered a problem addressed in the outpatient setting?
COMPREHENSION CHECK 3
1. MDM includes
3. A physician sees a new patient in the office. During the visit, he reviews 2 labs and an ultrasound from the referring external physician’s office. How many data elements should be counted?
4. A patient presents for a follow-up visit for acne on the face, chest, and back after having a change of medications at the last visit. She states that her acne does not seem much better, and she is still having flares. The physician documents that her condition is not at goal. What type of problem is this according to the CPT definitions in the 2021 E/M Guidelines?
5. The three elements of medical decision making (MDM) in the 2023 MDM Table are:
6. If a physician orders 2 labs and gets history from a patient’s caregiver due to the patient’s inability to convey a proper history, what level of Data Complexity would that support in the MDM table?
7. If a physician documents that a patient is having trouble staying compliant with their medications due to cost as they are unemployed and living in a shelter, what type of Risk of Complications from the MDM table does this support?
8. A male patient with sickle cell disease presents to the office with a vaso-occlusive crisis (VOC). The patient does not want to go to the hospital, so the physician agrees to try to help the patient manage the crisis at home. The physician tells the patient that if he is not better by the next day or the pain gets worse during the night, hospitalization will be required. What type of Risk of Complications from the MDM table does this support?
9. A patient with dehydration is admitted to observation at the hospital for iv fluids and to monitor their condition. What type of Problem Addressed from the MDM table does this support?
10. A cardiologist is called to see his patient on the Cardiac unit of the hospital. Due to the patient’s decompensation, they are moved to the Critical Care Unit. What type of Risk of Complications from the MDM table does this support?
COMPREHENSION CHECK 4
1. What are the four basic format elements of E/M services based on medical decision making or time?
2. Which of the following would be considered a problem addressed in the outpatient setting?
3. Which subcategory of E/M services have separate subcategories for new and established patients?
4. In order to report a consultation code, the following is required: a request from another physician/other qualified health care professional/appropriate source, a recommendation of care for a specific condition or problem and
5. What level of E/M service is supported by the following elements for a new patient: 1 chronic illness with severe exacerbation, review of an outside CT scan, ordering a lab test, and a new prescription given?
COMPREHENSION CHECK 4
6. What level of E/M service is supported by the following elements for an established patient: 2 minor/self-limited problems, no data reviewed, and prescription drug management?
7. A patient is seen in the office and 99215 is documented and this leads to the patient being admitted to observation at the hospital on the same day. The same physician that saw the patient in the office is the admitting physician. How should the services be reported by the physician according to CPT?
8. A patient is seen in the Emergency Department after a fall with left wrist, left lower leg, and right shoulder pain and swelling. A medically appropriate history and physical exam are performed. The physician orders complete x-rays of the wrist (73110) left ankle (73610), and right shoulder (73030) to rule out fractures. The x-ray reports are all negative. The patient is diagnosed with multiple sprains/strains, given a prescription for pain medication, and told to follow up with their primary care physician. What level of service does this documentation support?
9. A non-Medicare patient is admitted for a 7-day history of acute abdominal pain. A consultation is requested of Gastroenterology. The Gastroenterologist performs a medically appropriate history and physical exam. She reviews 4 unique tests and recommends the patient have a CT scan of the abdomen and pelvis today, and a colonoscopy in the near future to rule out diverticulosis and g.i. bleed as the patient does not have an indication for acute surgical intervention as of the visit today. The Gastroenterologist discusses the case with the patient’s primary care physician, states the patient will need close observation, and completes a consultation report in the shared medical record. What level of service does this documentation support?
10. A patient is seen and admitted with acute deep vein thrombosis, pulmonary embolism, and acute renal failure. He is started on iv heparin. A medically appropriate history and physical exam are performed. The admitting physician reviews 3 labs performed in the ED and an echocardiogram. Assessment/Plan: 1. Bilateral pulmonary embolism on iv heparin. Hypercoagulation studies ordered to rule out hereditary hypercoagulation. Leukocytosis. 3. Acute renal failure secondary to embolic right renal infarction. 4. Obesity. Patient will be placed on Coumadin for oral anticoagulation and may need temporary hemodialysis until renal function improves. Serial labs will be done to monitor for medication toxicity. What level of service does this documentation support for the admitting physician?
COMPREHENSION CHECK 4
11. For a nursing facility subsequent visit, the following are performed along with a medically appropriate history and physical exam: Moderate Problems Addressed, High Data Complexity, and Low Risk. What level of service does this documentation support?
12. A physician is preparing to see a non-Medicare patient in consultation in the office. She spends 20 minutes reviewing outside reports including labs, diagnostic tests, and recent hospitalization. She sees the patient and takes a medically appropriate history and physical examination. The visit time, including counseling and discussing treatment options with the patient, is 30 minutes. The physician calls the patient’s primary care physician and discusses her findings and recommendations. She then completes a written consultation report that is sent to the primary care physician. The discussion with the primary care physician takes 15 minutes. She spends another 15 minutes writing the consultation letter and entering information into the EMR for the patient. The Problem Addressed is Moderate, the Data analyzed is High, and the Risk is Moderate. What level of service does this documentation support?
13. A patient is placed in observation at the hospital at 9:00 am to monitor for chest pain, sweating, and nausea to rule out a myocardial infarction because the patient refused admission. 5 labs are ordered, along with an echocardiogram and an electrocardiogram. All testing comes back negative. The patient’s condition improves, and he is discharged with instructions to follow up with his physician within 48 hours at 10:00 pm the same day. What level of service does the documentation support?
14. A physician sees a new patient in the office and performs a medically appropriate history and physical exam. The Problems Addressed is 1 stable chronic illness, no data is analyzed or ordered, and the Risk is Moderate. What level of service does the documentation support?
15. What E/M levels must be documented in order to report Prolonged Services?