All of the following are types of E/M service EXCEPT:
A. urgent care.
B. emergency care.
C. office visit.
D. nursing facility care.
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Q. 2) Portable AP supine view of the chest demonstrates a Swan-Ganz catheter directed out the right pulmonary outflow tract.
Identify the portion of the medical record in which the following statements would MOST likely be found.
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Q. 3) The patient underwent umbilical hernia repair and went home that afternoon.
Identify the portion of the medical record in which the following statements would MOST likely be found.
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Q. 4) For what diagnosis would you likely see a prescription of oral Benadryl 50 mg tid prn, and prednisone 40, 30, 20, and 10 mg daily for 4 days.
A. Conjunctivitis
B. Pneumonia
C. Urticaria
D. Contusion
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Q. 5) PROCEDURE: The 42-year-old female patient is brought to the operating room where she was positioned, prepped and draped in the usual fashion for left breast biopsy. The patient was anesthetized utilizing intravenous administration of 75 mg of Demerol and 3 mg of Versed. The left upper outer breast was injected with 0.5 Marcaine with epinephrine.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Mass of the left upper outer breast.
POSTOPERATIVE DIAGNOSIS: Mass of the left upper outer breast.
PROCEDURE: Left breast biopsy.
ANESTHESIA: Local plus sedation.
A curvilinear incision was made overlying the mass. The incision was carried down through the subcutaneous tissue. The mass was excised along with approximately a nice 2 mm margin. Hemostasis was obtained utilizing a Bovie and electrocauterization. The specimen was sent to pathology for identification. The wound was copiously irrigated. Attention was turned to the dermis which was approximated with continuous 30 Dextron with closure of the epidermis achieved utilizing Steri-Strips. The patient was taken to the recovery room in satisfactory condition. The patient was returned to her room where she arrived in satisfactory condition. Pathology report reported returned as sebaceous cyst of the left upper outer breast.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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Q. 6) What is the appropriate E/M status and service for a 23-year-old female who was brought to the ER for a drug overdose and subsequently admitted to the ICU for monitoring and treatment?
A. Behavior change interventions, individual
B. Initial hospital admission
C. Subsequent observation care
D. Emergency department services, new or established patient
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Q. 7) Garamycin is a(-n):
A. operative procedure.
B. medication.
C. diagnosis.
D. laboratory test.
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Q. 8) OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Questionable stenosis of rectal anastomosis. POSTOPERATTVE DIAGNOSIS: Stenosis of rectal anastomosis.
PROCEDURE: Flexible sigmoidoscopy with dilatation of rectal anastomosis.
ANESTHESIA: Intravenous.
PROCEDURE: This 7-year-old female patient was brought to the endoscopy suite and placed in the left lateral decubitus position. A pediatric colonoscope was passed without difficulty though the anus. At 10 cm on the scope, the patient was found to have stenosis at the site of a previous rectal anastomosis. The anastomosis was very gently dilated until it could admit the scope. The scope was then passed through the anastomosis to the sigmoid colon where evaluation noted fairly normal anatomical features. The scope was then slowly withdrawn and the procedure terminated. The patient was returned to the recovery room is satisfactory condition.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
What will be an ideal response?
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Q. 9) The admission form is also known as the:
A. demographic sheet.
B. face sheet.
C. financial profile.
D. consent form.
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Q. 10) Which of the following IS permissible to code for the physician's office?
A. Past conditions that no longer exist
B. Chronic conditions treated multiple times
C. Preoperative diagnosis
D. Working diagnosis