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There must be a legible __ and __ on all pt charts to be elible for biling and coding
Date and signature
What are some factors that determine a coding level?
- Complexity of a problem
- New problem or existing problem
- Complexity of data interpretation
- Amt of time spent with the pt
- amnt of time spent reviewing the medical record
- risk that this pt may become sicker
A medication refil would be an example of a level __ in billing and coding?
(this multiple choice question has been scrambled)
A simple orthopedic injury with (ex. simple sprained ankle) is a level __ in billing and coding
(this multiple choice question has been scrambled)
___ is the billing level which represents problems of low to moderate severity and physician typically spends 20 mins face to face with the patietn and/or family. E/M rquires expanded problem focused history expanded problem focused examination and straightforward medical decision making.
____ is the billing level at which the problems are usually self limited or minor and the physician typically spends 10 mins face to face with the patient or family. E/M requries the following three components. Problem focused history, problem focused examination, straightforward medical decision making
__ is the billing level at which the presenting problems are of moderate severity and the physician typically spends 30 mins face to face with the pt or the family E/M requries the following 3 components: a detailed history, a detailed examination and a medical decision making of low complexity
___ is the billing level at which the presenting problems are of moderate to high severity and the physician typically spends 45 mins face to face with the patient and/or family EM requires the following three key components: comprehensive history, comprehensive examination and medical decision making of moderate complexity
__ is the billing level at which the presenting problems are of moderate to heigh severity and the physician typically spends 60 mins face to face with the patient and/or family. E/M requries the following three key components: comprehensive history, comprehensive examination, medical decision making of high complexity.
Admission of a diabetic pt with celluitis would be a level __ in billing and codin
Admission of a pts for acute colecystitis would be an example of a level __ exam in biling and coding
Admission of a pt for MI, with PMH of DM or CHF would be a level __ exam in biling and coding
What is the pneumonic for the anticholinergic toxidrome?
- Mad as a hatter (AMS)
- Blind as a bat (mydriasis)
- Hot as a hare (hyperthermic)
- Dry as a bone (dry skin, anhydrosis and urinary retention)
- Red as a beet (flushing)
- The heart runs alone (tachycardia and hypertension)
4 elements that determine the billing level of a history
- cheif complaint
- History of present illness
- Review of systems ROS
- past, Family and/or social histoyr
in the billing and coding world what are the two types of HPI?
- Brief: documentation of 1-3 elements (COLDERER only need 3)
- Extended: at least 4 elements of COLDERER or at least three chronic or inactive conditions mentioned that contribute to current state
___ is an inventory of body systems obtained by asking a series of questions in order to satisfy signs and/or symptoms that the pt may be experiencing or has espeirenced
___ is a concise statement describing the symptoms/problem or condition that prompted the pt visit it should be written in the pts own words
A problem focused ROS includes __ system(s) reviewed
A detailed ROS includes __ system(s) reviewed
A Comprehensive ROS includes __ system(s) reviewed
10 or more
a __ PMH/FHx and Social history is one where it is a reivew of the history areas directly related to the problems identified in the HPI
A __ PMH/FHx and social history is one where two or three of the areas are reviewed. a complete PFSH requries a review of all three history areas for services that by their nature include a comprehensive assessment or reassessment of the pt
A ___ PE includes 1-5 areas/organ systems evaluated
A ___ PE includes 1-5 systems or organs and at least 6 elements of one system
Expanded problem focused
A __ PE includes at least 6 systems or organs
A __ PE includes 9 or more organ or body systems evaluated
What are the two types of physical examination recognized by billing and coding?
- General multisystem examination: involves the examination of one or more organ systems or body areas
- Single organ system examination: which involves a more extensive examination of a specific organ system
T or F the notation of abnormal without eleboration on a portion of the PE is fine
False any abnormals must have elaboration and be described. NEVER document an entire organ system as negative only individual exams
What are the three big components of medical decision making as rated by billing and coding ?
- Diagnosis: the number of diagnoses or treatment options reviewed with the pt or by the examiner
- Complexity of Data Review: amnt of information that must be obtained and reviewed. history test results etc
- Risk of significant complications or Morbidity and Mortality: comorbidities, morbidity of presenting problem, morbidity of diagnostic proceedures, morbidity of managment options
A pt is in a high risk stratification if you they have .....
- one or more illnesses with sever exacerbation progression or side effects
- acute or chornic ellness that pose a threat of life or bodily function
- abrupt change in neurological function
A pt is at high risk stratification if you are ordering ...
- cardiovascular imaging studies with contrast or risk factors
- cardiac electrophysiological tests
- diagnostic endoscopy with risk factors
A pt is at high risk stratification if you are treating them with...
- elective major surgery with identified risk factors
- emergency major surgery
- drug therapy requriements intesnsive with monitoring for toxicity
- Decision for DNR or deescalate care b/c of poor prognosis
A pt is in moderate risk if they have...
- One or more chronic illnesses with mild exacerbation progressions or side effects
- two or more stable chronic illnesses
- undiagnosed new problem with uncertain prognosis
- Acute illness with systemic symptoms
The pt is defined as at moderate risk if you are ordering...
- obtaining fluid from a body cavity
- needle biopsy
The pt is defined as moderate risk if they will need a tx of
- elective minor surgery with no risk factors
- prescription drug managment
- therapeutic nuclear medicine
- IV fluids wtih addititives
A pt is at low risk if they have
- two or more self limited or minor problems
- one stable chronic illness
- acute uncomplicated illness
A pt is defined as low risk if you are ordering what tests
- physiologic tests not under stress
- non-CV imaging studies with contrast
- Superficial needle biopsies
- Skin biopsies
The pt is defined as low risk if they will need a treatment of..
- OTC drugs
- minor surgery
- IV fluid without additives
Level ___ is a problem focused history and exam and strighforward medical decision making
Level __ is an expanded exam, expanded history and a low medical decision making
Level __ is an expanded exam, and expanded history and an moderate medical decision making
Level __ is a detailed exam a detailed history and a moderate medical decions making
A level__ is a comprehensive exam, comprehensive history and high level of medical decsion making
What is a critical care code in billing and coding?
- a time based code so if you spend excessive face time with a very sick pt you get paid for that extra time
- used on critically ill pts
- critical care time is more than 30 mins by definition
- document with clock interval
Documentation of all pts encounters should include:
- reason for encounter and relevant history
- physical exam prior to diagnostic test results
- clinical impressions or diagnosis
- medical plan of care
- date and legible identity of observer
When documenting the discharge of a pt what is the "golden rule statement"?
- 1. return to the ED immediatly if worse or concerns or __
- 2. follow up with __ clinic in __ amnt of time