1. D. 4 years C. 3 years B. 2 years A. 1 year A patient is new if she has not seen another physician of the same specialty and in the same practice group for the past Click the Correct Choice

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3. A patient is new if s/he has received no care by a member of the billing physician’s same specialty and practice group in the past 3 years. Congratulations, that is Correct! Continue

4. D. Assessment and plan C. Physical exam B. History of present illness A. Chief Complaint No CPT code can be submitted without documentation of Click the Correct Choice

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6. < BackContinue A chief complaint is required for all CPT E &M codes. For established patients, only 2 of 3 key components must meet documentation requirements for CPT level. Even without documentation in one key area, a CPT code can still be reimbursed. Documentation should of course meet medical standards for clarity and completion aside from the billing standard minimums! Congratulations, that is Correct!

7. D. All the above C. Medications B. Past surgical history A. Allergies The following counts as assessment of past medical history Click the Correct Choice

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9. < BackContinue Allergies, medications, gynecologic history, preventive care history, immunizations, and prior surgical procedures are all considered assessment of past medical history. Congratulations, that is Correct!

10. D. 10 C. 2 B. 1 A. none You see an established patient for a new problem. You document a “detailed” HPI by using 4 or more historical descriptors. You also document the patient’s allergies and medications, which count as past medical history. You ask many ROS questions as well. How many of the ROS findings will you need to document for your history documentation to support coding level 4? Click the Correct Choice

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13. D. 10 C. 8 B. 5-7 A. 2 For an established patient, examination of how many organ systems must be documented to support level 5 coding? Click the Correct Choice

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15. < BackContinue Some institutions and Medicare intermediaries have defined level 4 “2- Detailed” documentation requirements Congratulations, that is Correct!

16. D. You can’t tell until the risk level is decided. C. Low, supporting a level 3 code, because 3 diagnoses are present but only 2 data review points are tallied (review tests, order test). B. High, supporting a level 5 code, because you are managing 3 chronic problems and managing lots of data. A. Moderate, supporting a level 4 code, because 3 diagnoses are present and 3 data review points are present (review lab, review radiology, order other test). A patient has 3 chronic problems requiring management. You need to review prior labs, review a bone density result, and order pulmonary function testing. The medical decision making level is: Click the Correct Choice

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18. < Back Congratulations, that is Correct! You’ve completed Quick Quiz #2. Close this window to return to Coding 101 Medical decision making level is determined by the higher 2 of the 3 subcomponent areas. Review of lab tests and ordering of lab tests each count as a separate data review point.