Which of the following best reflects the nature of the presenting problem?
a. Yesterday afternoon, she tripped on an ottoman in her house
b. Bruise on lower left leg was swollen, bruise is darker and warmer than the surrounding skin, and patient is undergoing anti-platelet therapy
c. Patient's adult daughter is concerned about her mother's health
d. PT/INR test is ordered to identify clotting concerns, patient has been educated about the signs and symptoms of a clot as well as the dangers of a deep vein thrombosis have been stressed
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Q. 2) Which of the following options best supports the type of service, or the patient type?
a. This is a new patient type of service because the problem is new to the physician
b. This is an established patient type of service because the patient has been treated by the physician within the previous three years
c. This is neither a new or established patient because the physician did not specifically document the patient type
d. Patient type is not applicable to this scenario
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Q. 3) Which of the following best reflects the type of service, or the patient type?
a. Established patient
b. New patient
c. One time visit
d. The documentation does not reflect this
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Q. 4) Which of the following best reflects the place of service of this documented service?
a. Emergency department
b. Nursing facility care
c. Inpatient hospital
d. Physician's office
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Q. 5) Which of the following best describes the service in the above medical documentation?
a. Surgical procedure
b. Radiology test
c. Evaluation and management
d. Medical diagnostic test
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Q. 6) What does AMA stand for?
a. All Medical Abbreviations
b. American Medical Association
c. American Medical Management Alliance
d. Asphyxiation Mitigation Assessment
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Q. 7) The content of the service is comprised of
a. the length of time the clinician spent with the patient in counseling or conversation.
b. history, physical examination, and medical decision making.
c. the devices used by the clinician during the E/M visit.
d. documentation methods, such as recorders, utilized at the time of the E/M visit.
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Q. 8) What does the type of service define?
a. The time of day when the E/M service began
b. The category of service, indicating the facility in which the E/M service occurred
c. The presence or absence of a specifically trained clinician, such as a nurse
d. The sub-category, which often suggests whether the patient is a new or established patient
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Q. 9) What does the term Place of Service define?
a. The location of the clinic in relation to the nearest hospital
b. The category of service, indicating the facility in which the E/M service occurred
c. The place where the clinician documents the E/M service
d. The sub-category, which often suggests whether the patient is a new or established patient
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Q. 10) Which of the following is NOT a constituent element that forms a specific, individual E/M service?
a. Place of the E/M service
b. Type of E/M service
c. Individually listed code
d. The language spoken by the patient
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