MOA 193 - Current Procedural Term Coding » Spring 2023 » Digital Review & Assignment 7

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Question #1
Which history classification captures a patient's chief complaint, expanded history of the present illness, the problem-pertinent system review extended to include a review of a limited number of additional systems, and pertinent past, family, and/or social history directly related to the patient's problem?
A.   Detailed history
B.   Expanded problem-focused history
C.   Comprehensive history
D.   Problem-focused history
Question #2
What is an HPI?
A.   A series of questions addressing each of the body systems
B.   A review of symptoms
C.   A notation of all negative symptoms
D.   A history of present illness
Question #3
What is the difference between a brief HPI and an extended HPI?
A.   A brief HPI includes four or more elements, while an extended HPI encompasses one to three elements.
B.   A brief HPI encompasses one to three elements and may involve a single problem without any complicating factors or symptoms, while an extended HPI includes four or more elements and is appropriate for complex or confusing symptoms, prolonged development, and when a patient's history is obtained from someone other than the patient themselves.
C.   A brief HPI and an extended HPI are the same thing.
D.   A brief HPI is appropriate for complex or confusing symptoms, while an extended HPI includes one to three elements
Question #4
What is a problem-pertinent system review?
A.   A series of questions addressing each of the body systems to uncover any signs and symptoms that the patient may be experiencing or has experienced
B.   A review of the patient's insurance coverage
C.   A review of the patient's financial status
D.   A review of the patient's medical records from previous visits
Question #5
Which history classification captures a patient's chief complaint and a brief history of the present illness or condition?
A.   Comprehensive history
B.   Problem-focused history
C.   Expanded problem-focused history
D.   Detailed history
Question #6
What is the purpose of capturing a patient's medical history?
A.   To keep a record of the patient's health status over time
B.   To bill the patient for services rendered
C.   To obtain demographic information about the patient
D.   To provide background information for medical decision-making
Question #7
How many categories of patient history are there?
A.   Two
B.   Four
C.   One
D.   Three
Question #8
What factors are considered to determine the appropriate level of E&M service codes?
A.   All of the reasons listed apply
B.   Only the complexity of medical decision making
C.   Only the examinations performed
D.   Only the extent of history obtained
Question #9
What is the importance of clear and detailed clinical documentation in medical decision making?
A.   It is important
B.   It is important for billing purposes only
C.   It can lead to better patient care, treatment initiatives, and physician or specialty referrals
D.   It is important only for legal purposes
Question #10
What is the purpose of a review of systems?
A.   To identify any signs and symptoms that the patient may be experiencing
B.   To document all negative symptoms
C.   To list all official body systems
D.   To assess constitutional symptoms
Question #11
What was the second system reviewed for Cecelia?
A.   Respiratory
B.   Musculoskeletal
C.   Constitutional
D.   Gastrointestinal
Question #12
What was the first system reviewed for Cecelia?
A.   Musculoskeletal
B.   Constitutional
C.   Respiratory
D.   Gastrointestinal
Question #13
How many systems were reviewed for Cecelia?
A.   Three
B.   One
C.   Four
D.   Two
Question #14
What is Cecelia's chief complaint?
A.   Diarrhea and vomiting
B.   Loss of appetite
C.   Night sweats
D.   Extended migraine headache
Question #15
What should a physician do if a notation is missing in the Complete ROS?
A.   Document at least 5 systems individually
B.   Document at least 9 systems individually
C.   Document at least 10 systems individually
D.   Document all body systems individually

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