Rules, germs, information (basic) needed to successfully pass entry level Medical Billing & Coding Certifications (AAPC CPC, & AHIMA CCS)
Terms : Hide Images
| 1075496117 | What symptoms are included in ROS (Review of Systems) for Constitutional Classification | - Usual weight. - recent weight changes, - fever, - weakness, - fatigue | 0 | |
| 1075496118 | What symptoms are included in ROS (Review of Systems) for Eyes (Ophthalmologic)Classification | - Glasses or contact lenses - last eye examination - visual glaucoma - cataracts - eyestrain - pain - diplopia, - redness - lacrimation - inflammation - blurring | 1 | |
| 1075496119 | What symptoms are included in ROS (Review of Systems) for Ear, Nose,Mouth, Throat (Otolaryngologic) Classification | - Ears: hearing discharge, tinnitus, dizziness, pain - Nose: head colds, epistaxsis (nosebleed),discharges, obstruction, postnasal drip, sinus pain - Mouth and throat: condition of teeth and gums, last dental examination, soreness, redness, hoarseness, difficulty in swallowing | 2 | |
| 1075496120 | What symptoms are included in ROS (review of Systems) for Cardiovascular Classification | - Chest pain, rheumatic fever, tachycardia, palpitation, high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis | 3 | |
| 1075496121 | What symptoms are included in ROS for Respiratory Classification | - Chest pain, wheezing, cough, dyspnea, sputum, (color and quantity), hemopytsis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleuirisy, last chest radiogeraph | 4 | |
| 1075496122 | What symptoms are included in ROS for Gastrointestinal Classification | - Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowed habits, diarrhea, constipation, indigestion, food intolerance, flatus, hemorrhiods, jaundice. | 5 | |
| 1075496123 | Genitourinary | ... | 6 | |
| 1075496124 | What symptoms are included in ROS for Urinary Classification | - frequent or painful urination, nocturia, pyuria, hematuria, incontinence, urinary infection, | 7 | |
| 1075496125 | What symptoms are included in ROS for Genitoreproductive Classification | Male: - veneral disease, sores, discharge from penis, hernias, testicular pain or masses Female: - age a menstruation (frequency, type, duration, dysmenorreha, monorrhagia, symptoms of menopause), contraception, pregnancies, deliveries, abortions, last Papanicolaou smear | 8 | |
| 1075496126 | What symptoms are included in ROS for Musculoskeletal Classification | Joint pain or stiffness, arthritis, gout, backache, muscle pain, cramps, swelling, redness, limitation in motor activity | 9 | |
| 1075496127 | What symptoms are included in ROS for Integumentary Classification (skin or breast) | Rashes, eruptions, dryness, cyanosis, jaundice, changes in skin, hair, or nails. | 10 | |
| 1075496128 | What symptoms are included in ROS for Neurologic (Neurological) Classification | Faintness, blackouts, seizures, paralysis, tingling, tremors, memory loss | 11 | |
| 1075496129 | What symptoms are included in ROS for Psychiatric Classification | Personality type, nervousness, mood, insomnia,. headache, nightmares, depression | 12 | |
| 1075496130 | What symptoms are included in ROS for Endocrine Classification | Thyroid trouble, heat or cold intolerance, excessive, sweating, thirst, hunger, or urination | 13 | |
| 1075496131 | What sympotoms are included in ROS for Hematologic.Lymphatic Classification | Anemia, easy bruising or bleeding, past transfusions | 14 | |
| 1075496132 | What symptoms are included in ROS for Allergic/Immunologic Classification | Sneezing, itching eyes, rhinorrhea, nasal obstruction, or recurrent infections, Environmental allergies, such as dust, mold, or latex | 15 | |
| 1075496133 | What does PFSH stand for | Past, Family, or social History | 16 | |
| 1075496134 | What items are included in the category of Past HIstory | - Prior major illinesses and injuries - Prior operations - Poor hospitalizations - Current medications - Allergies (e.g., drug, food) - Age-appropriate immunization status - Age-appropriate feeding/dietary status | 17 | |
| 1075496135 | What items are included in the category of Family History | Significant information about: - the health status or cause of death of parents, siblings, and children - Specific diseases related to problems identified in the CC, HPI, or ROS | 18 | |
| 1075496136 | What items are included in the category of Social History | An age-appropriate review of past and current activities that include significant information about: - Marital status and/or living arrangements - Current employment - Occupational history -Use of drugs, alcohol, and tobacco - Level of education - Sexual history - Other relevant social history | 19 | |
| 1075496137 | How many elements of a history are always included in varying degrees in all patient encounters | Three (3); - HPI - ROS - PFSH | 20 | |
| 1075496138 | How is the degree, level of HPI, ROS, and PFSH determined | They are determined by the CC (Chief complaint) or presenting problem of the patient during the current encounter that is being documented. | 21 | |
| 1075864033 | How many history levels are there, and what are they? | There are four levels - Problem focused - Expanded problem focused - Detailed - Comprehensive | 22 | |
| 1075864034 | What are the History levels based on to determine the level? | History levels are based on the extent of the history taken and the answered received during that process of the examination. They must be documented in the Medical Records in order to be referenced in the choice of History level. | 23 | |
| 1075864035 | What are the items included in a Problem Focused History level? | The Dr. focuses on the CC and a brief history of the present problem of a patient. A brief history includes" - A review of the history regarding pertinent information about the present problem or CC. - It centers around the severity, duration, and symptoms of the CC. - Does not have to include PFSH or ROS. | 24 | |
| 1075864036 | What are the items included in a Expanded Problem Focused History level? | The Dr. focuses on the CC, obtains a brief history of the present provblem, also performs a problem-pertinent review of systems. This hx includes: - a review of the Organ System (OS) most closely related to the CC - It requires 1 - 3 HPI elements, 1 OS mostly related to the CC, no PSFH | 25 | |
| 1075864037 | What are the items included in a Detailed focused History level? | The Dr. focuses on a CC and obtains an extended history of the present problem, and extended ROS, and a pertinent PFSH directly related to the patient's problem. - The extended ROS includes a review of the system directly related to the CC - Plus additional related systems - Requires at least 4 HPI, 2 - 9 ROS, at least 1 PFSH | 26 | |
| 1075864038 | What are the items included in a Comprehensive focused HIstory Level? | This is the most complex of the history types. The Dr. documents the CC, obtains an extended history, does a complete ROS, and obtains a complete PFSH. - Complete History, - Complete ROS - Complete PFSH | 27 | |
| 1075864039 | How to assign the history level using HPI, ROS, PFSH? | Normally whatever the HPI, then that would be what the History level would be; but if it is not definitive then a combination of whatever the most number levels are then that is the level of history. If all of the items are a number 2, but the PFHS is a level 4, then the History level would be a level 2. | 28 | |
| 1075864040 | If two blood pressures are taken, 1 standing, and 1 lying down, are both of them counted as an individual element for ROS | Yes they are. | 29 | |
| 1075864041 | Should you take for granted that a particular statement in a Medical Record is the actual item that should be coded? | No. When coding the entire medical record or report should be read in its entirety. No short cuts. | 30 | |
| 1075864042 | What are the four levels of examination | Problem focused Expanded problem focused Detailed Comprehensive | 31 | |
| 1075864043 | What are the general items listed in the Constitutional level of an exam (General) | - Blood pressure, sitting - Blood pressure lying - Pulse - Respiration - Temperature - Height - Weight - General appearance | 32 | |
| 1075864044 | What are the body areas that could be listed in an examination (BA) | - Head (including face) - Neck - Chest (including breasts and axillae) - Abdomen - Genitalia, groin, buttocks - Back - Each extremity | 33 | |
| 1075864045 | What are the Organ Systems that could be listed in an examination (OS) | - Ophthalmologic (eyes) - Otolaryngologic (ENT) - Cardiovascular - Respiratory - Gastrointestinal - Genitourinary - Musculoskeletal - Integumentary (skin) - Neurologic - Psychiatric - Hematologic/Lympohatic/Immunologic | 34 | |
| 1075864046 | What are the items included in a Problem focused examination | It is limited to the affect OS or BA. Includes 1 OS or BA | 35 | |
| 1075864047 | What are the items included in an Expanded problem focused examination | It ia a limited examination of the affected BA or OS and other related BA's or OS's. It involves a limited examination of 2 - BAs or OSs. | 36 | |
| 1075864048 | What are the items included in a Detailed examination. | It is an extended examination of the affected BA's or related Os's It involves an extended examination of 2 - 7 BAs or OSs. | 37 | |
| 1075864049 | What are the items included in a Comprehensive examination. | This is the most extensive examination; it includes at least 8 BAs or OSs. | 38 | |
| 1075864050 | What is the difference of the expanded and detailed examination, containing 2 - 7 Ba's or OSs. | The difference: - The expanded problem focused examination is limited and is focused on the BA/OS of the CC and the other directly related BAs, OSs. - The detailed examination is extended and covers not only the related BAs/OSs, but also BAs/OSs not directly related to the CC. | 39 | |
| 1075864051 | What does MDM stand for | Medical Decision Making | 40 | |
| 1075864052 | What are the three elements that MDM are based on | 1. Number of Dx or management options. They can be minimal, limited, multiple, or extensive 2. Amount or complexity of data to review. The data can be minimal/none. limited, moderate, or extensive. 3. Risk of complications or death, if the condition goes untreated. Risk can be minimal, low, moderate, or high | 41 | |
| 1076340173 | What does the number of Dx or management options the must exist for pertinent documentation to choose the correct level of MDM | For each encounter, an assessment, clinical impression, or Dx should be documented. it can be explicitly stated or implied in documented decisions regarding management plans or further evaluation | 42 | |
| 1076340174 | What documentation should be included in the medical records to uphold and determine the level of MDM for a presenting problem (CC) | With an established dx: The record should reflect whether the problem is - a improved, well-controlled, resolving, or resolved - inadequately controlled, worsening or failing to respond Without an established dx: The record may be stated as a differential diagnoses or as - possible -probable -rule out (R/O) diagnosis | 43 | |
| 1076340175 | What documentation should be included in the medical record to initiate, change, treatment of a patient. | The record should include a wide range of management options - patient instructions - nursing instructions - therapies - medications | 44 | |
| 1076340176 | What documentation should be included in the medical record for using referrals, consultations, or seeking advice. | The record should indicate - to whom the referral/consultation is made - to where the referral/consultation is made - or from whom the advice is requested | 45 | |
| 1076340177 | What is the documentation that should be included for the amount and complexity of data to be reveiwed | 1. If a diagnostic service (test/procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service (e.g. laboratory or radiology) should be documented 2. The review of laboratory, radiology, or other diagnostic tests should be documented (an entry in the progress note such as WBC elevated, chest x-ray unremarkable, is acceptable) It may also be documented by initializing and dating the report containing the test results. 3. Decision to obtain medical records or additional information from any source should be documented 4. Relevant findings from the review of old records/receipt of additional history from any source should be documented. If there IS additional information (more than already documented) document. If no additional information was found after reviewing the old records, that much be documented as well. (with full disclosure) 5. The results of discussion of laboratory, radiology, or other diagnostic tests with the Dr. who performed or interpreted the study should be documented. 6. The direct visualization and independent interpretation of an image, tracing, or specimen previously interpreted by another physician should be documented. | 46 | |
| 1094245272 | What are some of the basic documentation guidelines for risk of significant complications, morbidity, or mortality? | 1.Factors that increased the complexity of MDM should be documented - comorbilities -underlying diseases -or other factors 2- If a specific surgical or invasive diagnostic procedure is ordered during the E/M evaluation, document it. 3. If a surgical or invasive diagnostic procedure is performed during the E/M encounter, than document it. 4. If a referral for or decision to perform a surgical or invasive diagnositc procedure is performed on an urgent basis, then document it. | 47 | |
| 1094245273 | What are the levels of risk to determine MDM complexity | - Straightforward - Low - Moderate - High | 48 | |
| 1094245274 | What is straightforward decision making? | -Minimal diagnosis and/or management options -Minimal/no amount of complexity of data reviewed -Minimal risk to the patient of complications/or death if untreated | 49 | |
| 1094245275 | What is low-complexity decision making? | -Limited number of diagnoses/or management options -Limited data to be reviewed -Low risk of death/complications to patient if untreated | 50 | |
| 1094245276 | What is Moderate-complexity decision making? | -Multiple diagnoses and/or management options -Moderate amount/complexity of data to be reviewed -Moderate risk to the patient of complications or death if untreated. | 51 | |
| 1094436347 | What is High-complexity decision making? | -Extensive diagnoses and/or management options -Extensive amount/complexity of data to be reviewed -High risk to the patient for complications or death if the problem is untreated | 52 | |
| 1094436348 | How many elements of a given level of must be met to select a MDM Level? | Two to three elements must be met or exceed. | 53 | |
| 1094436349 | How many elements of a given level must be met to select a History level? | All three elements of the given History level must be met or exceeded. | 54 | |
| 1094436350 | What are contributing factors when choosing a MDM level? | There are four: -Counseling -Coordination of care -Nature of the presenting problem -Time | 55 | |
| 1094436351 | What is a definition of contributing factors? | Contributing factors are: those conditions that help the physician to determine the extent of history, examination, and decision making (key components) necessary to treat a patient. | 56 | |
| 1094436352 | What is counseling? | Counseling is a service that physicians provide to patients and their families. It includes: -Discussion of diagnostic results, impressions, recommended diagnostic studies -prognosis -risks and benefits of treatment -instructions for treatment -importance of compliance with treatment -risk factor reduction -patient and family education -The code is based on the total time spent counseling as documented in the medical record | 57 | |
| 1094436353 | What is coordination of care? | The primary physician, or ordering physician makes arrangements for the patient to have other services done that cannot be performed by the ordering physician, but have the results of those studies forwarded back to the ordering physician for evaluation. | 58 | |
| 1094436354 | What is Nature of the Presenting Problem? | The Presenting problem is normally the (CC) or the situation that leads the physician into determining the level of care necessary to diagnose and treat the patient. It is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter. | 59 | |
| 1094436355 | What are the five types of presenting problems? | 1. Minimal 2. Self-limited 3. Low severity 4. Moderate severity 5. High Severity | 60 | |
| 1094436356 | What is a minimal presenting problem? | It is a problem that may not require a physician to be present, but requires treatment to be under a physician supervision. Ex. blood pressure reading a dressing change or another service performed without a physician present | 61 | |
| 1094436357 | What is a Self-limited presenting problem? | Also called minor problem. It runs a definite and prescribed course. It is transient (it comes and goes) not likely to alter health status permanently, or the presenting problem has a good prognosis with management and compliance. | 62 | |
| 1094436358 | What is a Low severity presenting problem? | The risk of complete sickness (morbidity) without treatment is low. -there is little or no death without treatment -and a full recovery without impairment is expected | 63 | |
| 1094436359 | What is a Moderate severity presenting problem? | The risk of complete sickness (morbidity) without treatment is moderate -there is moderate risk of death without treatment -an uncertain prognosis or increased probability of impairment exists. | 64 | |
| 1094436360 | What is a High severity presenting problem? | The risk of complete sickness (morbidity) without treatment is high to extreme, -there is a moderate to high risk of death without treatment -a strong probability of severe, prolonged functional imparment | 65 |
