A 38-year-old man presents his regular clinic for a same day appointment to address his severe abdominal pain, diarrhea, and headache. His regular physician is not available and the new physician sees the patient. The physician documents a detailed history, expanded problem focused physical examination, and a moderate medical decision making. What is the MOST appropriate overall level for the E/M service?
A. Office or other outpatient site, new patient Level 4
B. Office or other outpatient site, established patient Level 3
C. Office or other outpatient site, new patient, Level 3
D. Office or other outpatient site, established patient, Level 4
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Q. 2) During a new patient office visit, the physician documents an expanded problem focused history and physical examination for a patient with abdominal pain, diarrhea, difficulty sleeping, and headaches; history reveals the patient drinks in excess of five cups of coffee daily. Medical decision making is low. However, because the patient is so concerned about the abdominal pain and diarrhea, the physician spends a total of 45 minutes counseling the patient on proper dietary and bowel habits, stress reduction, and recommendations for limitation of caffeine intake. What is the MOST appropriate overall level for the E/M service?
A. Office or other outpatient site, established patient, Level 4
B. Office or other outpatient site, established patient Level 3
C. Office or other outpatient site, new patient Level 4
D. Office or other outpatient site, new patient, Level 3
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Q. 3) A 47-year-old woman presents to her regular physician with a chief complaint of painful urination and dizziness. The woman has been living in a different state for five years; this is her first visit after returning to the area. The physician documents a comprehensive history, a detailed physical examination, and a moderate medical decision making. What is the MOST appropriate overall level for the E/M service?
A. Office or other outpatient site, new patient Level 2
B. Office or other outpatient site, established patient Level 3
C. Office or other outpatient site, new patient, Level 3
D. Office or other outpatient site, established patient, Level 4
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Q. 4) Which of the following BEST defines a presenting problem of minimal severity?
A. A problem that, if untreated, has a high risk of significant morbidity or mortality or an extreme, negative impact on the patient's health or ability to function
B. A problem that may not require the presence of a physician, but is provided under the supervision of a physician
C. A problem that has a specific course and is not chronic in nature, and is not likely to permanently impact the patient's long term health, and poses little risk of mortality without treatment
D. A problem that, if untreated, may lead to increased morbidity and may even significantly impact the patient's health or ability to function
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Q. 5) Which of the following phrases BEST describes when time may be the controlling factor when determining a particular level of E/M service?
A. When extenuating circumstances, such as involvement of belligerent or hyper-involved family members or non-family care providers, preclude direct face to face interaction between the physician and the patient, time may be the controlling factor when determining a particular level of E/M service
B. When circumstances require the involvement of more than one physician during the course of the E/M service visit, time may be the controlling factor when determining a particular level of E/M service
C. When circumstances, such as the physiologic state or advanced pathology of the patient, prevent the physician from thoroughly documenting the history in detail, time may be the controlling factor when determining a particular level of E/M service
D. When circumstances require more than 50 percent of the E/M service visit to be spent in coordination of care and/or counseling, time may be the controlling factor when determining a particular level of E/M service
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Q. 6) Which of the following is required to document unit/floor intraservice time?
A. Documentation of the time spent by the physician in review of patient records while in transit to the patient's unit, floor, or bedside
B. Documentation of the physician's presence on the patient's hospital unit or floor and at the patient's bedside
C. Documentation of the physician's independent review of diagnostic results in the presence of the physician, radiologist or pathologist who performed the diagnostic testing
D. Documentation of the policy of the facility in which the physician has performed the E/M service
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Q. 7) Physician performs an E/M service visit for a patient who has never been treated at the clinic. The physician documents a comprehensive history, expanded problem focused physical examination, and a low medical decision making. What is the overall level of E/M service?
A. Level 2
B. Level 3
C. Level 4
D. Level 5
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Q. 8) When using only the components history, physical examination, and medical decision making to determine the overall level of the service for an E/M service performed for an established patient in an office or other outpatient setting, which of the following elements are required?
decision making are required
B. The medical decision making is the most important to support an E/M service performed for a new patient in an office or other outpatient
C. Only two of the three components - history, physical examination, and medical decision-making are required to support an E/M service performed for a new patient in an office or other outpatient
D. New patient requires only documentation of the intraservice time regardless of the documentation of the service
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Q. 9) Which of the following is the BEST example of coordination of care?
A. The physician performing the E/M service contacts a general surgeon requesting a diagnostic laparoscopy to rule out an abdominal mass
B. The physician performing the E/M service reviews the patient's previous medical records before the patient arrives at the clinic
C. The physician performing the E/M service discusses the importance of visiting the dentist during the E/M service
D. The physician performing the E/M service encourages the patient to coordinate all healthcare visits in order to prevent a lapse in healthcare
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Q. 10) Which of the following is required to document face-to-face intraservice time?
A. Documentation of any counseling provided for the patient during the E/M service visit and/or patient's family during the E/M service visit
B. Documentation of the collection of history, performance of the physical examination and making the medical decisions for the plan of care
C. Documentation of the physician's coordination of the patient's care or the physician's independent review of diagnostic results or images, all of which must occur in the patient's presence during the course of the E/M service visit
D. Any or all of the above
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