Relias Part 1 Exam Questions with Correct Rationales.

Relias Part 1 Exam Questions with Correct Rationales A clinical psychologist provided psychiatric services to a 35-year-old patient diagnosed with depression. The psychologist spent 45 minutes with the patient discussing her problems and reasons for her depression. How is this reported? - Ans: 90834-AH The focus of the health behavior assessment and intervention codes () is on mental health. - Ans: False A psychiatrist was called to the high school because one of her patients was on the roof of the building threatening to jump. Once she got there, it took her 30 minutes to talk this patient off the ledge, and she spent another 35 minutes calming the patient down and getting him to come inside. How is this reported? - Ans: 90839 A physician performs an initial health and behavior assessment using Skype to interview the patient, who lives in a remote rural area. The total face-to-face time with the patient and the time spent integrating and interpreting data at the completion of the entire episode of evaluation is documented as 45 minutes. How is this reported? - Ans: 96116-95 Which is an example of a clinical staff member based on the CPT definition of "clinical staff"? - Ans: Registered nurse What code(s) should be used to report psychotherapy sessions that last 90 minutes? - Ans: 90837, 99354 Where are codes for reporting psychiatric services located in the CPT code set? - Ans: Medicine and Evaluation and Management (E/M) Services sections What code is reported for the psychotherapy for an established patient involving 25 minutes of face-to-face time with the patient, in addition to time spent doing an expanded problem-focused physical examination and medical decision-making of low complexity? - Ans: 99213, 90833 The psychiatrist sees an established patient for medication management and a prescription refill, does an interval history and mental status exam, and refills the patient's prescription medication, but provides no psychotherapy. What code should be reported? - Ans: 99212 During a calendar month, a behavioral health care manager who is providing psychiatric collaborative care services may also separately report what other services? - Ans: Psychotherapy Which is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter? - Ans: chief complaint A preterm infant is transported from the facility where he was delivered by a neonatologist to a receiving facility. The physician assumes primary responsibility for the neonate at the referring hospital and provides face-to-face critical care for 105 minutes during transport to the receiving hospital; the time ends when the receiving hospital accepts responsibility for the patient's care. What code(s) should be reported? - Ans: 99466, 99467 A patient is seen by an orthopedic surgeon at the request of his primary care physician. During the first visit, the orthopedic surgeon performs a therapeutic procedure and after completing the visit, documents his opinion and the services performed in a report to the patient's PCP. What category of E/M services is reported for this visit? - Ans: office consultation In which section do the most substantial differences between the Centers for Medicare & Medicaid Services' (CMS) 1995 and 1997 E/M documentation guidelines occur? - Ans: examination Which type of medical decision-making requires an extensive number of diagnoses or management options, involves an extensive amount and/or complexity of data to be reviewed, and poses a high risk of complications and/or morbidity or mortality? - Ans: high complexity Which of the following refers to the complexity of establishing a diagnosis or selecting a management option? - Ans: Medical decision-making What are the three key components used to select a level of hospital inpatient E/M service? - Ans: History, exam, medical decision-making A physician makes a home visit to an established patient with hypertension and peripheral vascular disease. The patient is hemiplegic and has been homebound for 2 years after a stroke. The physician performs an expanded problem-focused interval history, a problem-focused examination, and straightforward medical decision-making. What is the appropriate category of E/M codes and the appropriate level of service for this encounter? - Ans: 99347 What is the correct E/M reporting if a patient is seen in a physician's office and is then admitted to the hospital by the same physician on that day? - Ans: Inpatient admission If a patient is assigned observation status and is subsequently admitted to the hospital on the same date, how should the E/M services provided be reported? - Ans: Initial hospital care For office or other outpatient visits, what is/are the key or controlling factor(s) to qualify for a particular level of E/M service? - Ans: Medical decision making or time Which component is included in the four types of medical decision-making recognized in the CPT code set? - Ans: complexity of data reviewed In general, what do the categories of service within the E/M section depend on? - Ans: Site of service At the initial office visit for a new patient, a 6-year-old boy presents with a 2-day history of lower abdominal pain with occasional vomiting. A detailed history is obtained, including gastrointestinal system, fever, appetite, and characteristics of pain and bowel movements. A detailed examination is performed, including examination of the chest, abdomen, and rectum. Medical decision-making is of low complexity. Appropriate laboratory studies are ordered, and plans for surgical consultation are also initiated. What is the appropriate E/M code for this encounter? - Ans: 99203 What severity defines a presenting problem with a moderate-to-high risk of mortality without treatment or a high probability of severe, prolonged functional impairment? - Ans: high A 22- year-old male established patient goes to the physician's office seeking information about the human immunodeficiency virus (HIV). He did not want an examination but said he wanted to learn all he could from an expert. The documentation indicates the physician spent 10 mintues reviewing the medical history form completed by the patient and the total length of time spent counseling the patient was 30 minutes. What is the correct code for this encounter? - Ans: 99214 A 2-month-old girl was seen in the emergency department because she had difficulty breathing. A detailed history and examination and high-complexity medical decision-making are documented. The pediatrician admitted the patient on the same day to the pediatric intensive care unit and provided critical care services. What code(s) should be reported? - Ans: 99471 When reporting care for newborns and pediatric patients, what determines which category of codes to use? - Ans: Age of the patient What is a chronological description of the development of the patient's chief complaint from the first sign and/or symptom to the present? - Ans: HISTORY OF PRESENT illness An 85-year-old female made an appointment with her regular physician to discuss creating a living will, a health care proxy, and completing a Medical Orders for Life-Sustaining Treatment form. Her physician spends 30 minutes with her, helping her with these forms. What E/M code(s) should the physician report? - Ans: 99497 A 57-year-old male went to see his family physician at his office with complaints of stomach pain and difficulty eating. After examining him and reviewing his history of present illness, the physician told the patient he was going to admit him to the hospital right away to rule out appendicitis. The physician called in the order and accompanied the patient to the hospital, where he wrote up the admission history and physical examination. From which E/M subsection(s) will the physician's services be reported? - Ans: Initial hospital care The obstetrician requested that the neonatologist be in attendance at the delivery of a baby, due to shoulder dystocia, so she could provide initial stabilization for the neonate. What code should be reported for the neonatologist? - Ans: 99464 A physician provides an E/M service to a patient in the office on Wednesday, and the patient is subsequently admitted to the hospital on that same day. However, the physician does not have an inpatient encounter with the patient until Thursday morning. What E/M code(s) should this physician report? - Ans: Office visit, established patient + initial hospital care For a new patient encounter (99205), prolonged services code 99417 may be reported when the encounter reaches 75 minutes of service time. - Ans: true Dr. Martin was asked by Dr. Lincoln to evaluate a patient in the hospital. Dr. Martin performed a detailed history and exam. His medical decision-making was straightforward. Dr. Martin communicated his findings to Dr. Lincoln in a written report. What E/M code should Dr. Martin report? - Ans: 99252 A primary care physician admitted her patient to the hospital in the morning with concerns about his severe abdominal pain. In the afternoon, the patient passed a kidney stone, and the pain disappeared. The primary care physician performed a comprehensive history, comprehensive exam, and medical decision-making of moderate complexity that same afternoon, and discharged the patient home. What E/M code(s) should the physician report? - Ans: 99235 A physician went to see her patient, an 87-year-old male, for his monthly nursing home visit. She documented a problem-focused interval history, and the medical decision-making was straightforward. However, the physician did not examine the patient because he was too agitated. What E/M code should the physician report? - Ans: 99307 A 61-year-old male patient was brought into the emergency department (ED) after having lost consciousness in a grocery store. The ED physician took an expanded problem-focused history and performed a detailed exam. The medical decision-making was of moderate complexity. What E/M code should be reported for the ED physician? - Ans: 99283 A 7-year-old female was brought in by her mom to see her pediatrician for her annual back-to-school physical. What code would be used to report this service? - Ans: 99393 Code-level selection for which type of E/M services is based on total time on the day of the encounter or medical decision making? - Ans: Office or other outpatient The physician performs an E/M service for an established patient. The service includes obtaining a Pap smear and performing a pelvic examination, a breast examination, and a blood pressure check. Counseling is provided on diet and exercise, substance use, and sexual activity. How is this service reported? - Ans: Preventive medicine service Which E/M codes require that the physician perform a "medically appropriate history and/or examination." - Ans: Office or other outpatient A patient is referred by his primary care physician to an orthopedic surgeon for evaluation. During the first visit, the orthopedic surgeon initiates diagnostic or therapeutic service, and after the visit is completed, reports his opinion back to the primary care physician. How would this encounter be reported? - Ans: Consultation When subsequent hospital care is reported, all three of the key components must meet or exceed the stated requirements to report the E/M service. - Ans: False The time ranges specified in which E/M services code descriptors include face-to-face and non-face-to-face time? - Ans: Office and other outpatient What are the three key components used to select a level of E/M service? - Ans: History, exam, medical decision-making A patient is referred to a surgeon for treatment of a specific condition. How does the surgeon report the related E/M services? - Ans: New patient office visit When the healthcare professional obtains a medical history, what term describes the symptom, problem, condition, or other reason for the E/M encounter (usually stated in the patient's words)? - Ans: chief complaint For reporting a level of E/M service from the Initial Hospital Care subcategory, how many key components must meet or exceed the stated requirements to qualify for a particular level of service? - Ans: All three What is the difference between an Expanded Problem Focused (EPF) exam and a Detailed exam? - Ans: An EPF exam requires a limited examination of one or more areas/systems, and a Detailed exam requires an extended examination of one or more areas/systems. What body area/organ system is documented in this entry: "During the examination, the patient was able to demonstrate good judgment and reason, without hallucinations, abnormal affect, or abnormal behaviors." - Ans: psychiatric Which body area/organ system is documented in this entry: "Pedal pulses positive; extremities negative for edema or varicosities." - Ans: Cardiovascular Referring to the 1997 E/M documentation guidelines, which level of service requires documentation of two elements in each of six body areas or organ systems, or of 12 elements from two or more body areas or organ systems? - Ans: detailed examination What differentiates the 1995 E/M documentation guidelines from the 1997 documentation guidelines? - Ans: 1997 guidelines include specialty-specific examination information. What level of physical examination is documented in this entry: "Vital signs stable. Significant nasal congestion; oral mucosa pink and moist; TMs normal." - Ans: problem focused Which examination documentation is considered inadequate documentation? - Ans: The patient's examination seemed unremarkable, with a BP of 124/74; however, a BP recheck was abnormal. In the E/M examination component, which body area or organ system would include documentation of examination of blood pressure, pulse rate, respiration, temperature, height, weight, and general appearance? - Ans: Constitutional What level of physical examination is documented in this entry: "Abdomen: soft, nontender, BSx4. Respiratory: Lung CTA, no wheezing or rhonchi." - Ans: Expanded problem focused Which body area/organ system is documented in this entry: "Symmetric expansion on inspection; tactile fremitus was present equally bilaterally on palpation; resonant on percussion; no rales or rhonchi noted bilaterally." - Ans: respiratory In the selection of a level of E/M service, which component contains these five elements: minimal, self-limited or minor, low severity, moderate severity, and high severity? - Ans: presenting problem How many systems are included in this ROS: "The patient denies fever, chest pain, seizures, and swelling or edema of the extremities." - Ans: 3 Which scenario documents an extended history of the present illness? - Ans: The patient complains of fever and frequent episodes of hacking, nonproductive cough accompanied by chest pain when coughing. Symptoms started 1 week ago after exposure to a sick child. The patient has taken Tylenol for the fever. Which scenario documents a complete review of systems? - Ans: The patient denies neck stiffness, fever, rash; difficulty with speech, swallowing, or gait; numbness, diarrhea, constipation, weight loss or gain, chest pain, shortness of breath, or cough. All other systems have been reviewed and are negative. What types of history are defined for E/M services? - Ans: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive Who can perform an HPI? - Ans: Attending physician or nurse practitioner Which scenario documents a complete past, family, social history for an initial inpatient encounter? - Ans: The patient is retired and lives with his wife. He denies smoking and illicit drugs. He has NKDA. No prior surgeries. His parents are alive and well at age 70. What is the chief complaint for this encounter: "This patient with a history of diabetes, not currently stable on the current medication regimen, is here for follow-up and medication refill." - Ans: Diabetes What level of HPI is supported by this documentation: "An established patient presents with complaints of nasal congestion symptoms that have been ongoing for approximately 2 weeks. She has been taking OTC sinus medication without relief. The patient states that her 'face hurts' and she occasionally experiences increasing cranial pressure when bending over." - Ans: Extended HPI What type of history focuses on the period of time since the physician last performed an assessment of the patient? - Ans: Interval According to the CPT Level of Medical Decision Making (MDM) table, what level of risk is associated with elective major open surgery? - Ans: Moderate A patient is seen in the office for a lump in her right breast with breast pain. After reviewing the mammography and ultrasound results, the physician schedules a deep needle biopsy. The patient's breast pain is treated with nonsteroidal antiinflammatory drugs (NSAIDs). What is the level of risk associated with this encounter? - Ans: Moderate Initialing and dating a report of laboratory test results is sufficient documentation of the review of data. - Ans: True When are economic and social conditions that influence a patient's health relevant in E/M level selection? - Ans: When they significantly limit diagnosis or treatment. A patient presents to the clinic with persistent pain in the right wrist after a fall. An x-ray is ordered and shows no acute fractures. The physician diagnoses a right wrist sprain and places the patient in a padded splint. The patient is given nonsteroidal antiinflammatory drugs (NSAIDs) and asked to return in 1 week. What is the level of medical decision-making for this encounter? - Ans: low Which are considered the key components used to select a level of E/M service? - Ans: History, exam, medical-decision-making Which best defines medical decision-making? - Ans: The complexity of establishing a diagnosis or selecting a management option. Which of the following defines a problem according to CPT E/M guidelines? - Ans: A condition addressed at the encounter with or without a diagnosis being established at the time of the encounter. What are the four types or levels of complexity in medical decision making? - Ans: straightforward, low, moderate, and high According to the CPT E/M guidelines in the criteria for the data element, who is considered an "appropriate source" for discussion of management? - Ans: Non-healthcare professionals involved in the management of the patient. A patient presented to the Emergency Department for pain following a fall onto the left shoulder and arm and the provider diagnosed a closed proximal metaphyseal humeral fracture. What is the correct coding for this diagnosis? - Ans: S42.295A Which is true when coding multiple injuries? - Ans: Code each injury separately. A patient presents with severe lower back pain, both at rest and with activity, and bruising after slipping and falling getting out of the shower at home. Provider documents lower back pain due to muscle strain. What is the correct coding for this case? - Ans: S39.012A, W18.2XXA A patient is seen in the emergency department (ED) for acute gastroenteritis, nausea with vomiting, and abdominal pain. The patient was advised to rest and drink fluids when. What diagnosis/diagnoses should be reported? - Ans: Acute gastroenteritis What is the correct sequencing when the condition is a poisoning? - Ans: A poisoning code is sequenced first with additional codes for any manifestations. What is the correct coding and sequencing when a patient presents for outpatient surgery and develops complications and is admitted to observation? - Ans: Code the reason for the surgery as the first-listed diagnosis and the complication as an additional code. A patient presents to her physician's office with complaints of urinary frequency and burning. The lab report indicates urinalysis was positive for bacteria and increased white blood cells and the urine culture demonstrated high levels of bacteria consistent with urinary tract infection. What is the correct coding for this encounter? - Ans: Urinary frequency and burning. A patient presents to the physician's office for a routine physical exam. After examination, the patient's physician sends a urine specimen to the cytology lab for analysis with a diagnosis of hematuria. What is the diagnosis coding for this office visit? - Ans: Z00.01, R31.9 A patient, who is coughing, with shortness of breath, is referred to a radiologist for a chest x-ray with a diagnosis of "rule out pneumonia." The radiologist performs a chest x-ray, and the results are acute bronchitis due to Streptococcus. What is the first-listed code for this case? - Ans: J20.2 A patient presented to the physician's office with sunburn on the face and chest after spending too much time in a tanning bed. What is the correct coding for this encounter? - Ans: L56.8, W89.1XXA A 49-year-old patient was seen by his physician for pain in the left lower abdomen and diarrhea. The physician orders blood tests and a CT scan and documents "rule out Crohn's disease." What is the appropriate code assignment for this encounter? - Ans: Abdominal pain, diarrhea A patient with stage IV uterine cancer presents to the emergency department with intractable lower abdominal pain. She is treated with Dilaudid and oxycodone for pain management. - Ans: G89.3, C55 Codes from which category are assigned for a routine prenatal outpatient visit involving supervision of a patient due to past history of ectopic pregnancy? - Ans: O09 A patient is treated in the urgent care clinic for acute gastroenteritis, nausea with vomiting, and abdominal pain. What is the appropriate diagnosis reporting for this encounter? - Ans: Acute gastroenteritis Which is the correct diagnosis coding for "MRSA infection of the gastrostomy with cellulitis of the abdominal wall"? - Ans: K94.22, L03.311, B95.62 What coding convention provides sequencing by the instructions "code first", "use additional code" and "in diseases classified elsewhere" notes? - Ans: Etiology/manifestation The physician documents the patient's diagnosis as acute cholecystitis with cholelithiasis and choledocholithiasis. What is the appropriate code assignment? - Ans: K80.62 Which ICD-10-CM Guidelines apply when coding outpatient hospital services and physician office visits? - Ans: Selection I and IV The physician ordered physical and occupational therapy for a patient with a history of acute cerebral infarction with residual right-sided weakness (dominant side). What is the appropriate code assignment? - Ans: I69.351 Which outpatient coding guideline is different from the guideline for reporting inpatient diagnoses? - Ans: Reporting inconclusive diagnoses Which is true when coding multiple injuries? - Ans: Code each injury separately.