MEDICAL BILLING & CODING -
CERTIFICATION TESTS QUESTIONS
WITH VERIFIED ANSWERS
What are the Organ Systems that could be listed in an examination (OS) - Answer--
Ophthalmologic (eyes)
- Otolaryngologic (ENT)
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin)
- Neurologic
- Psychiatric
- Hematologic/Lympohatic/Immunologic
What are the items included in a Problem focused examination - Answer-It is limited
to the affect OS or BA.
Includes 1 OS or BA
What are the items included in an Expanded problem focused examination - Answer-
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.
What are the items included in a Detailed examination. - Answer-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.
What are the items included in a Comprehensive examination. - Answer-This is the
most extensive examination; it includes at least 8 BAs or OSs.
What is the difference of the expanded and detailed examination, containing 2 - 7
Ba's or OSs. - Answer-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.
What does MDM stand for - Answer-Medical Decision Making
What are the three elements that MDM are based on - Answer-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
, What does the number of Dx or management options the must exist for pertinent
documentation to choose the correct level of MDM - Answer-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
What documentation should be included in the medical records to uphold and
determine the level of MDM for a presenting problem (CC) - Answer-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
What documentation should be included in the medical record to initiate, change,
treatment of a patient. - Answer-The record should include a wide range of
management options
- patient instructions
- nursing instructions
- therapies
- medications
What documentation should be included in the medical record for using referrals,
consultations, or seeking advice. - Answer-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
What is the documentation that should be included for the amount and complexity of
data to be reveiwed - Answer-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.
CERTIFICATION TESTS QUESTIONS
WITH VERIFIED ANSWERS
What are the Organ Systems that could be listed in an examination (OS) - Answer--
Ophthalmologic (eyes)
- Otolaryngologic (ENT)
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin)
- Neurologic
- Psychiatric
- Hematologic/Lympohatic/Immunologic
What are the items included in a Problem focused examination - Answer-It is limited
to the affect OS or BA.
Includes 1 OS or BA
What are the items included in an Expanded problem focused examination - Answer-
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.
What are the items included in a Detailed examination. - Answer-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.
What are the items included in a Comprehensive examination. - Answer-This is the
most extensive examination; it includes at least 8 BAs or OSs.
What is the difference of the expanded and detailed examination, containing 2 - 7
Ba's or OSs. - Answer-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.
What does MDM stand for - Answer-Medical Decision Making
What are the three elements that MDM are based on - Answer-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
, What does the number of Dx or management options the must exist for pertinent
documentation to choose the correct level of MDM - Answer-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
What documentation should be included in the medical records to uphold and
determine the level of MDM for a presenting problem (CC) - Answer-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
What documentation should be included in the medical record to initiate, change,
treatment of a patient. - Answer-The record should include a wide range of
management options
- patient instructions
- nursing instructions
- therapies
- medications
What documentation should be included in the medical record for using referrals,
consultations, or seeking advice. - Answer-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
What is the documentation that should be included for the amount and complexity of
data to be reveiwed - Answer-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.
