E-M Week 2 Quiz

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These elements would be part of the_____ history: employment, education, use of Drugs.


The level of E/M service is based on:

Key components

The HPI must be documented in the medical record by:

the physician

The observation examination is the ___ portion of the E/M service?


MDM is based on the ____ the physician must consider about the management of a patient’s condition.

All of the above

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

An acute care facility

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


Critical care codes are reported based on:


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

Skilled nursing facility

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


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


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 extend ROS, and a pertinent PFSH. What is the level of History?


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

Expanded Problem Focused

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?


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


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


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

Int’l con’t intensive care service

An initial inpatient consulation with a detailed history, detailed exam and MDM of low complexity.


A 40 year-old est. patient presents to the physician office for a preventive care exam


History and Exam of the normal newborn infant born in a hospital setting?


Complete the following blanks that refer to the three factors that the coder must consider in the assignment _____ of service, _____ of service, ______ status

POS, Type, patient

The code range for Home Service is _______


The four types of patient status are____. ____, ______ and _____

New, Est. Inpatient, Outpatient

Matching: Location


Matching: Quality


Matching: Severity

worst I’ve ever had

Matching: Duration

since last night

Matching: Timining


Matching: Context

on exertion

Matching: Modifying factors

some relief with rest

Matching: Associated signs and systems

some shortness of breath

The most extensive examination that encompasses a complete single specialty examination or complete multisystem examination is___________


Examination is limited to the affect body area or organ system and other related organ system is________

Expanded Problem Focused

Examination is limited to the affected body area or organ system identified by the chief complaint is _______


An extended examination of the affected body area or areas and related organ system(s) is____


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