BIO391: ScribeAmerica Outpatient
Course 6 Billing and Coding 100%
Accurate
T/F Every level of billing requires a chief complaint to be documented - ANSWER T
Fix this non-reimbursable term so that it is reimbursable:
3 month Check-up (DM) - ANSWER 3 month diabetes (DM) maintenance visit
Fix this non-reimbursable term:
Follow-up for HTN - ANSWER HTN management evaluation (or: management and
evaluation of chronic illness(es), list)
Fix this non-reimbursable term:
Lab results (elevated TSH levels) - ANSWER Discuss treatment options for elevated
TSH
Fix this non-reimbursable term:
Medication refill for lisinopril - ANSWER Evaluation of medication management for HTN
The ______________________ is the level of service for the visit which determines the
amount of eligible reimbursement - ANSWER Evaluation and management (E&M) level
There are five different levels of service: - ANSWER 1. Minimal
2. Problem-focused visit
3. Expanded problem-focused
4. Detailed
5. Comprehensive
The most commonly used E&M levels are _______________ - ANSWER 3, 4
E&M Level 4: # HPI Elements for new pt - ANSWER 4
E&M Level 4: # HPI Elements for established pt - ANSWER 2
E&M Level 4: # ROS Elements for new pt - ANSWER 10
E&M Level 4: # ROS Elements for established pt - ANSWER 2
, E&M Level 4: # PMHx for new pt - ANSWER 3
E&M Level 4: # PMHx for established pt - ANSWER 1
E&M Level 4: # PE findings and # PE systems for new pt - ANSWER 18, 9
E&M Level 4: # PE findings and # PE systems for established pt - ANSWER 12, 2
E&M Level 4: # assessments/plans for new pt - ANSWER 1
E&M Level 4: # assessments/plans for established pt - ANSWER 2
Review: list the HPI elements - ANSWER Onset, Location, Quality, Timing, Modifying
factors, Associated symptoms, context
List the ROS systems (section 6.4) - ANSWER constitutional, eyes, ENT,
cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal,
neurological, integumentary (skin), psychiatric (psych), hematologic (heme/lymph),
endocrine, immune/allergy
For established patients only, you can document "reviewed past history", but you must
also document the ____________ - ANSWER Date and time of the last visit
Review: go back to the Outpatient Course 4 set and review the normal exam findings for
each of the 13 systems - ANSWER I reviewed the normal exam findings
A Level 4 assessment and plan includes - ANSWER 1. Problems
2. Data
3. Health risk
The A/P visit data can include - ANSWER 1. 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 - ANSWER 1.
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 - ANSWER level of
service
Course 6 Billing and Coding 100%
Accurate
T/F Every level of billing requires a chief complaint to be documented - ANSWER T
Fix this non-reimbursable term so that it is reimbursable:
3 month Check-up (DM) - ANSWER 3 month diabetes (DM) maintenance visit
Fix this non-reimbursable term:
Follow-up for HTN - ANSWER HTN management evaluation (or: management and
evaluation of chronic illness(es), list)
Fix this non-reimbursable term:
Lab results (elevated TSH levels) - ANSWER Discuss treatment options for elevated
TSH
Fix this non-reimbursable term:
Medication refill for lisinopril - ANSWER Evaluation of medication management for HTN
The ______________________ is the level of service for the visit which determines the
amount of eligible reimbursement - ANSWER Evaluation and management (E&M) level
There are five different levels of service: - ANSWER 1. Minimal
2. Problem-focused visit
3. Expanded problem-focused
4. Detailed
5. Comprehensive
The most commonly used E&M levels are _______________ - ANSWER 3, 4
E&M Level 4: # HPI Elements for new pt - ANSWER 4
E&M Level 4: # HPI Elements for established pt - ANSWER 2
E&M Level 4: # ROS Elements for new pt - ANSWER 10
E&M Level 4: # ROS Elements for established pt - ANSWER 2
, E&M Level 4: # PMHx for new pt - ANSWER 3
E&M Level 4: # PMHx for established pt - ANSWER 1
E&M Level 4: # PE findings and # PE systems for new pt - ANSWER 18, 9
E&M Level 4: # PE findings and # PE systems for established pt - ANSWER 12, 2
E&M Level 4: # assessments/plans for new pt - ANSWER 1
E&M Level 4: # assessments/plans for established pt - ANSWER 2
Review: list the HPI elements - ANSWER Onset, Location, Quality, Timing, Modifying
factors, Associated symptoms, context
List the ROS systems (section 6.4) - ANSWER constitutional, eyes, ENT,
cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal,
neurological, integumentary (skin), psychiatric (psych), hematologic (heme/lymph),
endocrine, immune/allergy
For established patients only, you can document "reviewed past history", but you must
also document the ____________ - ANSWER Date and time of the last visit
Review: go back to the Outpatient Course 4 set and review the normal exam findings for
each of the 13 systems - ANSWER I reviewed the normal exam findings
A Level 4 assessment and plan includes - ANSWER 1. Problems
2. Data
3. Health risk
The A/P visit data can include - ANSWER 1. 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 - ANSWER 1.
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 - ANSWER level of
service
