Current Procedural Terminology (CPT) - CORRECT ANSWER used by physicians and other healthcare
providers. It is considered Level I of the HCPCS.
History of Present Illness - CORRECT ANSWER description of its development from the first sign or
symptom that the patient experienced to the present time.
Past Medical History - CORRECT ANSWER the patient's experiences with illnesses, injuries, and
treatments in addition to operations, injuries and hospitalizations.
Family History - CORRECT ANSWER reviews the medical history of the patient's family.
Social History - CORRECT ANSWER patient's age, marital status, employment, etc.
Chief complaint - CORRECT ANSWER Of present illness, review of symptom,Past, Family and or Social
History
History Levels - CORRECT ANSWER Problem focused, expanded problem focused, Detailed,
Comprehensive
Examination Levels - CORRECT ANSWER Problem focused, expanded problem focused, Detailed,
Comprehensive
Medical Decision-Making Complexity Levels - CORRECT ANSWER Straightforward, Low, Moderate, High
Straightforward - CORRECT ANSWER Minimal diagnosis, Minimal Risk, Minimal complexity of data
Low - CORRECT ANSWER Limited diagnosis, Limited/Low risk to patient, Limited data
, Moderate - CORRECT ANSWER Multiple diagnoses, Moderate risk to the patient, Moderate amount of
complexity of data
High - CORRECT ANSWER Extensive diagnoses , High risk to patient, Extensive amount and comp,lexity of
data
Physical Status Modifiers - CORRECT ANSWER P1 A normal healthy patient
P2 - CORRECT ANSWER A patient with mild systemic disease
P3 - CORRECT ANSWER A patient with severe systemic disease
P4 - CORRECT ANSWER A patient with severe systemic disease that is a constant threat to life
P5 - CORRECT ANSWER A moribund patient who is not expected to survive without the operation
P6 - CORRECT ANSWER A declared brain-dead patient whose organs are being removed for donor
purposes-
HCPCS Anesthesia Modifiers - CORRECT ANSWER AA Anesthesia services personally performed by the
anesthesiologist
AD - CORRECT ANSWER Supervision, more than four procedures
QK - CORRECT ANSWER Medical direction of two, three, or four concurrent anesthesia procedures
QS - CORRECT ANSWER Monitored Anesthesia Care (MAC) services (can be billed by a qualified
nonphysician anesthetist or physician)
QX - CORRECT ANSWER Qualified non-physician anesthetist with medical direction by a physician