Coding 101 Quiz - Key Documentation Requirements in Medical Billing

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

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3. Congratulations, that is Correct! 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. Continue

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

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6. Congratulations, that is Correct! 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! < Back Continue

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

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

10. Click the Correct Choice 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? A. none B. 1 C. 2 D. 10

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

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

16. Click the Correct Choice 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: 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). B. High, supporting a level 5 code, because you are managing 3 chronic problems and managing lots of data. C. Low, supporting a level 3 code, because 3 diagnoses are present but only 2 data review points are tallied (review tests, order test). D. You can’t tell until the risk level is decided.

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18. Congratulations, that is Correct! 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. You’ve completed Quick Quiz #2. Close this window to return to Coding 101 < Back