Questions and Answers
What does BP stand for in medical abbreviations?
In the context of Mr. Andrews' visit to Dr. Parker, which category of evaluation and management codes would be selected?
What category of evaluation and management codes would be selected for the well child exam for the 2-year-old patient?
For John, who was admitted for observation after an ATV accident, which evaluation and management code should be selected?
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What category of evaluation and management services would Dr. Hedrick's follow-up visit after surgery be reported?
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What category and subcategory of evaluation and management code would be selected for Ashley's visit to Dr. Howard for knee pain?
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What E/M code is reported for the established patient with a left tibia fracture?
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What E/M code is reported for the new patient with low back pain and a history of spinal stenosis?
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For the new patient with a right inguinal hernia, what E/M code is reported?
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For the established patient following up after a CT scan, what E/M code is reported?
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For the established patient with a history of lower abdominal pain, what E/M code is reported?
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What is the level of exam based on the physical exam documentation showing six organ systems examined?
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What is the level of exam based on the thorough documentation of a comprehensive female exam?
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What is the level of exam based on the physical exam showing eight organ systems examined?
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What is the level of exam for the physical exam described? A. Problem focused B. Expanded problem focused C. Detailed D. Comprehensive
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What is the level of exam for the physical exam described? A. Problem focused B. Expanded problem focused C. Detailed D. Comprehensive
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What is the level of medical decision making for the patient with uncontrolled DM2? A. Straightforward B. Low C. Moderate D. High
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What is the level of medical decision making for the ED visit with pulmonary edema? A. Straightforward B. Low C. Moderate D. High
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What is the level of medical decision making regarding the mastectomy for gynecomastia? A. Straightforward B. Low C. Moderate D. High
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What is the level of medical decision making for the hospitalization due to CHF exacerbation? A. Straightforward B. Low C. Moderate D. High
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What is the level of medical decision making for the hospital visit concerning gallstones and reflux? A. Straightforward B. Low C. Moderate D. High
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What E/M code is reported for the ED visit for migraine? A. 99282 B. 99283 C. 99284 D. 99285
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What is the appropriate E/M code for a hospital visit with a comprehensive exam and high-level medical decision making? A. 99221 B. 99222 C. 99223 D. 99234
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What E/M code is reported for the new patient with severe ear pain in the ED? A. 99282 B. 99283 C. 99284 D. 99285
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What is the appropriate E/M code for the nursing home visit examining electrolyte imbalance? A. 99307 B. 99308 C. 99309 D. 99310
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What is the appropriate E/M consultation code for the patient with ulnar neuropathy? A. 99242 B. 99243 C. 99244 D. 99245
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Study Notes
Medical Abbreviations
- BP: Blood Pressure
- CC: Chief Complaint
- HEENT: Head, Eyes, Ears, Nose, Throat
- HPI: History of Present Illness
- Hx: History
- NAD: No Apparent Distress
- NKDA: No Known Drug Allergies
- PE: Physical Examination
- PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation
- PMH: Past Medical History
- R/O: Rule Out
- ROS: Review of Systems
- WNL: Within Normal Limits
Outpatient Consultation
- A 34-year-old male, Mr. Andrews, evaluated for neurological issues indicating weakness and pain in the left arm.
- Consultation initiated by Dr. Smith, coded as Outpatient Consultation.
Well Child Exam
- 2-year-old patient undergoes an annual checkup and vaccinations with Dr. Denton.
- This visit is categorized as Preventive Medicine for an established patient.
Observation Care
- 16-year-old John admitted for observation post-ATV accident.
- Emergency department physician's services coded as Initial Observation Care since the patient remained under observation.
Non-Billable Follow-Up
- Dr. Hedrick, a neurosurgeon, provides a follow-up visit post-surgery within the global period, making it non-billable.
New Patient Visit
- 26-year-old female, Ashley, evaluated for knee pain by Dr. Howard, an orthopedist, resulting in diagnosis of a torn ACL.
- As this was her first visit to this provider, it is coded as an Office Visit for a New Patient.
Established Patient Office Visit
- 13-year-old male for follow-up on left tibia fracture shows compliance and low complexity of issues.
- Visit is categorized as an Established Patient Visit, with E/M code 99213.
Complexity in Visits
- A 78-year-old female with spinal stenosis evaluated for exacerbating pain marks her visit as an Established Patient Visit, coded as 99204 due to moderate complexity and additional testing required.
Right Inguinal Hernia
- 44-year-old athletic male reporting right groin pain and bulge classified as an Office Visit for a New Patient, coded as 99203.
Established Patient Follow-Up
- A follow-up visit for abdominal pain assessment reveals a subtle abnormality in the CT scan.
- This encounter is coded as 99214, reflecting moderate complexity with a new undiagnosed problem.
Detailed and Comprehensive Exams
- Physical exams can be classified based on documentation guidelines:
- Detailed exam involves six organ systems.
- Comprehensive exam assesses eight systems, reflecting thorough examination.
Expanded Problem Focused Exam
- Exam involving a healthy child with mild issues classified as Expanded Problem Focused due to involvement of three organ systems.
Levels of Examination
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Levels range from Problem Focused to Comprehensive, determined by the number of organ systems and complexity of data involved:
- Detailed for more extensive patient evaluations.
- Comprehensive for complete body system assessments.### Medical Exam Levels and Decision Making
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Exam Levels:
- Comprehensive: Involves detailed examination across multiple organ systems; assessed when extensive data is gathered and thorough history is taken.
- Expanded Problem Focused: Includes examination relevant to the presenting problem with an extended history.
- Detailed: Involves a comprehensive history but includes only notable examination findings.
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Medical Decision Making (MDM) Levels:
- Straightforward: Minimal or no significant risk; stable chronic problems without complications.
- Low: Involves established problems with some worsening; low risk involved in management.
- Moderate: Established problem with notable exacerbation; involves moderate risk, additional work-up, or management options.
- High: New problems with significant risk or serious illness; involves extensive work-up or intervention.
Specific Cases
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Uncontrolled Diabetes Mellitus (DM2):
- Patient with A1C of 8.5; medical decision making categorized as Moderate due to chronic conditions and follow-up plan.
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Emergency Department (ED) Visit Findings:
- Pulmonary edema noted; no acute MI. Medical decision making High due to new problem and requirement for dialysis.
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Gynecomastia Case:
- Consultation for ultrasound review showed cystic lesion leading to a recommendation for simple mastectomy; medical decision making Low as it involves an established problem.
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Subsequent Hospital Visit:
- Management of congestive heart failure exacerbation and acute renal failure; categorized as High due to multiple worsening issues.
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Cholelithiasis and Reflux:
- Patient with severe symptoms scheduled for laparoscopic cholecystectomy; medical decision making Moderate as it involves elective surgery.
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Migraine Patient in ED:
- Patient presenting with severe migraine and possible viral infection; E/M code reported as moderate due to complexity and required CT/lumbar puncture.
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Lung Transplant Admission:
- Comprehensive history and high-level decision making led to an E/M code of 99223.
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Nursing Home Visit:
- Exam focused on dizziness with electrolyte imbalance history; E/M code was 99309 based on detailed history and moderate MDM.
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Neurologist Consultation:
- Evaluation of ulnar neuropathy and carpal tunnel syndrome; the appropriate E/M consultation code was 99243 reflecting detailed history and moderate risk involved.
Coding Key Components
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E/M Coding Components:
- History of Present Illness (HPI): Descriptive account of the patient’s condition.
- Review of Systems (ROS): Inventory of patient symptoms across organ systems.
- Past, Family, and Social History (PFSH): Relevant past health, family health issues, and social circumstances.
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Determining E/M Codes:
- E/M codes based on the level of history, examination type, and medical decision making risk level involved in patient management.
- Codes categorized from 99201 to 99285 cover various contexts, with higher numbers representing more complex cases.
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Description
Test your knowledge of essential medical abbreviations with these flashcards. This quiz includes terms like BP, HPI, and PE, crucial for understanding medical charts and patient evaluations. Perfect for medical students and professionals looking to sharpen their skills.
