The sentence Chest X-ray ordered to rule out lung congestion or esophageal mass. support independent visualization of image, scan or film.
Impression: 29-year-old woman with possible extraesophageal manifestation of GERD.
Plan: Chest X-ray ordered to rule out lung congestion or esophageal mass. Upon review of X-ray, consider proton pump inhibitor therapy and change of lifestyle to reduce stress and improve digestion, including eating five small meals throughout day and no food or drink three plus hours before bedtime.
Indicate whether this statement is true or false.
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Q. 2) The phrase CBC normal supports the review of diagnostic testing.
Read the following case study excerpt and answer questions 1 and 2.
ECG: Sinus bradycardia, with peaked T waves and widened QRS noted. No ST depressions. Poor R wave progression.
Laboratory:
CBC normal
Comprehensive metabolic panel: significant for sodium 122, potassium 6.7, chloride 96, bicarbinate 12, BUN 101, creatinine 4.0.
Impression: 68-year-old male with acute renal failure and secondary metabolic acidosis with hyperkalemia and bradycardia
Indicate whether this statement is true or false.
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Q. 3) How many different documentation guidelines are listed by the 95 and 97 DGs for the amount and/or complexity of data?
A. Two
B. Four
C. Six
D. Eight
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Q. 4) How does diagnostic testing assist the physician performing the E/M visit?
A. Results of lung auscultation
B. Listening to the sounds produced in an organ or body cavity
C. Reviewing clinical, laboratory, pathology, or radiology results
D. Coordination with pharmacy for a prescription for hydrocodone cough suppressant
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Q. 5) Identify the data to be reviewed and the complexity of the data to be reviewed when the physician obtains additional history from someone other than the patient.
A. Straightforward
B. Low
C. Moderate
D. High
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Q. 6) Which of the following choices is BEST considered data?
A. Collected history
B. The physical structure of the human body
C. Independently review the film of the chest X-ray
D. Discussion of chief complaint with patient
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Q. 7) Identify the data to be reviewed and the complexity of the data to be reviewed when the physician performing the E/M visit independently reviews the image, tracing, or scan.
A. Straightforward
B. Low
C. Moderate
D. High
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Q. 8) Identify the data to be reviewed and the complexity of the data to be reviewed when the physician performing the E/M visit discusses the diagnostic results with the physician who performed the diagnostic testing.
A. Straightforward
B. Low
C. Moderate
D. High
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Q. 9) Which of the following best identifies the data to be reviewed and the complexity of the data to be reviewed when the physician obtains old records?
A. Straightforward
B. Low
C. Moderate
D. High
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Q. 10) Identify the data to be reviewed and the complexity of the data to be reviewed when the physician orders diagnostic data.
A. Straightforward
B. Low
C. Moderate
D. High
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