BIO391: ScribeAmerica Outpatient Course 6 Billing and Coding Exam 100% Accurate!!

BIO391: ScribeAmerica Outpatient
Course 6 Billing and Coding Exam 100%
Accurate!!
T/F Every level of billing requires a chief complaint to be documented - ANSWERST

Fix this non-reimbursable term so that it is reimbursable:

3 month Check-up (DM) - ANSWERS3 month diabetes (DM) maintenance visit

Fix this non-reimbursable term:

Follow-up for HTN - ANSWERSHTN management evaluation (or: management and
evaluation of chronic illness(es), list)

Fix this non-reimbursable term:

Lab results (elevated TSH levels) - ANSWERSDiscuss treatment options for elevated
TSH

Fix this non-reimbursable term:

Medication refill for lisinopril - ANSWERSEvaluation of medication management for
HTN

The ______________________ is the level of service for the visit which determines the
amount of eligible reimbursement - ANSWERSEvaluation and management (E&M) level

There are five different levels of service: - ANSWERS1. Minimal
2. Problem-focused visit
3. Expanded problem-focused
4. Detailed
5. Comprehensive

The most commonly used E&M levels are _______________ - ANSWERS3, 4

E&M Level 4: # HPI Elements for new pt - ANSWERS4

E&M Level 4: # HPI Elements for established pt - ANSWERS2

E&M Level 4: # ROS Elements for new pt - ANSWERS10

, E&M Level 4: # ROS Elements for established pt - ANSWERS2

E&M Level 4: # PMHx for new pt - ANSWERS3

E&M Level 4: # PMHx for established pt - ANSWERS1

E&M Level 4: # PE findings and # PE systems for new pt - ANSWERS18, 9

E&M Level 4: # PE findings and # PE systems for established pt - ANSWERS12, 2

E&M Level 4: # assessments/plans for new pt - ANSWERS1

E&M Level 4: # assessments/plans for established pt - ANSWERS2

Review: list the HPI elements - ANSWERSOnset, Location, Quality, Timing, Modifying
factors, Associated symptoms, context


The A/P visit data can include - ANSWERS1. Reviewing/ordering labs
2. Reviewing/ordered imaging
3. Obtaining old medical records
4. Reviewing/summarizing old medical records
5. Obtaining history from someone other than pt
6. Independent interpretation

The A/P problem "scale of complexity" in order of increasing complexity - ANSWERS1.
Self-limited diagnosis
2. Established problem, stable/improved
3. Established problem, uncontrolled/worse
4. New problem, no work up
5. New problem, with work up

The E&M code determines the ________________ for the visit - ANSWERSlevel of
service

If ________% of the patient encounter is spent with face-to-face counseling, you can bill
for counseling time. - ANSWERS>50

Mrs. Smith is a new patient, and her note contains the items below. Is this a level 3 or
level 4 visit? If not a level 4, why?

-3 elements of HPI
-9 ROS systems
-only PMHx and SHx (surgical history)
-9 PE systems