MEDICAL CODING AND BILLING TEST QUESTIONS AND ANSWERS

MEDICAL CODING AND BILLING TEST QUESTIONS AND ANSWERS What symptoms are included in ROS (Review of Systems) for Constitutional Classification - ANSWER-- Usual weight. - recent weight changes, - fever, - weakness, - fatigue What symptoms are included in ROS (Review of Systems) for Eyes (Ophthalmologic)Classification - ANSWER-- Glasses or contact lenses - last eye examination - visual glaucoma - cataracts - eyestrain - pain - diplopia, - redness - lacrimation - inflammation - blurring What symptoms are included in ROS (Review of Systems) for Ear, Nose, Mouth, Throat (Otolaryngologic) Classification - ANSWER-- Ears: hearing discharge, tinnitus, dizziness, pain - Nose: head colds, epistaxis (nosebleed),discharges, obstruction, postnasal drip, sinus pain - Mouth and throat: condition of teeth and gums, last dental examination, soreness, redness, hoarseness, difficulty in swallowing What symptoms are included in ROS (review of Systems) for Cardiovascular Classification - ANSWER-- Chest pain, rheumatic fever, tachycardia, palpitation, high blood pressure, enema, vertigo, faintness, varicose veins, thrombophlebitis What symptoms are included in ROS for Respiratory Classification - ANSWER-- Chest pain, wheezing, cough, dyspnoea, sputum, (colour and quantity), haemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last chest radiograph What symptoms are included in ROS for Gastrointestinal Classification - ANSWER-- Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowed habits, diarrhoea, constipation, indigestion, food intolerance, flatus, haemorrhoids, jaundice. What symptoms are included in ROS for Urinary Classification - ANSWER-- frequent or painful urination, nocturia, pyuria, haematuria, incontinence, urinary infection, What symptoms are included in ROS for Genito reproductive Classification - ANSWER-Male: - venereal disease, sores, discharge from penis, hernias, testicular pain or masses Female: - age a menstruation (frequency, type, duration, dysmenorrhea, menorrhagia, symptoms of menopause), contraception, pregnancies, deliveries, abortions, last Papanicolaou smear What symptoms are included in ROS for Musculoskeletal Classification - ANSWER-Joint pain or stiffness, arthritis, gout, backache, muscle pain, cramps, swelling, redness, limitation in motor activity What symptoms are included in ROS for Integumentary Classification (skin or breast) - ANSWER-Rashes, eruptions, dryness, cyanosis, jaundice, changes in skin, hair, or nails. What symptoms are included in ROS for Neurologic (Neurological) Classification - ANSWER-Faintness, blackouts, seizures, paralysis, tingling, tremors, memory loss What symptoms are included in ROS for Psychiatric Classification - ANSWER-Personality type, nervousness, mood, insomnia,. headache, nightmares, depression What symptoms are included in ROS for Endocrine Classification - ANSWER-Thyroid trouble, heat or cold intolerance, excessive, sweating, thirst, hunger, or urination What symptoms are included in ROS for Hematologic. Lymphatic Classification - ANSWER-Anaemia, easy bruising or bleeding, past transfusions What symptoms are included in ROS for Allergic/Immunologic Classification - ANSWER-Sneezing, itching eyes, rhinorrhoea, nasal obstruction, or recurrent infections, Environmental allergies, such as dust, Mold, or latex What does PFSH stand for - ANSWER-Past, Family, or social History What items are included in the category of Past HIstory - ANSWER-- Prior major illinesses and injuries - Prior operations - Poor hospitalizations - Current medications - Allergies (e.g., drug, food) - Age-appropriate immunization status - Age-appropriate feeding/dietary status What items are included in the category of Family History - ANSWER-Significant information about: - the health status or cause of death of parents, siblings, and children - Specific diseases related to problems identified in the CC, HPI, or ROS What items are included in the category of Social History - ANSWER-An age-appropriate review of past and current activities that include significant information about: - Marital status and/or living arrangements - Current employment - Occupational history -Use of drugs, alcohol, and tobacco - Level of education - Sexual history - Other relevant social history