ADVANCED HEALTH ASSESSMENT & CLINICAL
DIAGNOSIS 2026 COMPREHENSIVE QUESTION
SET WITH RATIONALES AND CLINICAL
DECISION-MAKING REVIEW
◉ You administered the CAGE questionnaire as part of a screening
policy and the patient answers yes to 2 and 4. what is the
significance of this if any?
Answer: he has physical dependence and needs intervention
◉ what does question 4 on the CAGE questionnaire ask? what is the
significance of it?
Answer: do they need an eye opener? it indicates physical
dependence
◉ you are meeting for the first time a 14 y/o female patient. you
would want to include the what in her exam?
Answer: HEADS & RAFFT
◉ what does HEADS & RAFFT assess
Answer: behavior of the teenager
,◉ patient scores a 29 on the mini-mental exam. what do you
document this as?
Answer: a normal finding
◉ what are the components of the adult health history?
Answer: 1. identifying data
2. history of present illness
3. review of systems
NOT physical exam
◉ what does the CAGE questionnaire look for
Answer: alcoholism
◉ coronary artery disease risk factors (4)
Answer: 1. smoking
2. HTN
3. family history
4. age
◉ you have a new patient and in order to get reimbursed at a higher
level for education you provide, you must document the time spent
on this education at least what percentage of the visit
, Answer: at least 55% of the visit
◉ how do you define an established patient
Answer: patient presents for a checkup in your office. you have not
seen her before but she was last seen by the MD in your group 2
years ago
◉ how long would it be since a patient has been seen in the same
practice for them to be considered a new patient
Answer: 3 years ago
◉ as you review your note for your patient you realize that the keys
to select the right level of billing include what 3 things
Answer: history
exam
decision making
◉ when performing a history & physical on a pediatric patient,
which important factor affects the outcome the most:
Answer: child's development level
◉ the key element for all levels of CPT code documentation is:
Answer: chief complaint
DIAGNOSIS 2026 COMPREHENSIVE QUESTION
SET WITH RATIONALES AND CLINICAL
DECISION-MAKING REVIEW
◉ You administered the CAGE questionnaire as part of a screening
policy and the patient answers yes to 2 and 4. what is the
significance of this if any?
Answer: he has physical dependence and needs intervention
◉ what does question 4 on the CAGE questionnaire ask? what is the
significance of it?
Answer: do they need an eye opener? it indicates physical
dependence
◉ you are meeting for the first time a 14 y/o female patient. you
would want to include the what in her exam?
Answer: HEADS & RAFFT
◉ what does HEADS & RAFFT assess
Answer: behavior of the teenager
,◉ patient scores a 29 on the mini-mental exam. what do you
document this as?
Answer: a normal finding
◉ what are the components of the adult health history?
Answer: 1. identifying data
2. history of present illness
3. review of systems
NOT physical exam
◉ what does the CAGE questionnaire look for
Answer: alcoholism
◉ coronary artery disease risk factors (4)
Answer: 1. smoking
2. HTN
3. family history
4. age
◉ you have a new patient and in order to get reimbursed at a higher
level for education you provide, you must document the time spent
on this education at least what percentage of the visit
, Answer: at least 55% of the visit
◉ how do you define an established patient
Answer: patient presents for a checkup in your office. you have not
seen her before but she was last seen by the MD in your group 2
years ago
◉ how long would it be since a patient has been seen in the same
practice for them to be considered a new patient
Answer: 3 years ago
◉ as you review your note for your patient you realize that the keys
to select the right level of billing include what 3 things
Answer: history
exam
decision making
◉ when performing a history & physical on a pediatric patient,
which important factor affects the outcome the most:
Answer: child's development level
◉ the key element for all levels of CPT code documentation is:
Answer: chief complaint
