Question 1

The CPT comprehensive history includes the __________.
A) chief complaint and brief history of present illness or problem
B) chief complaint, brief history of present illness or problem, and problem-pertinent system review
C) chief complaint, extended HPI, problem-pertinent system review extended to include a limited number of additional systems, and pertinent PFSH directly related to the patient's problem
D) chief complaint, extended HPI, ROS directly related to the problem(s) identified in the HPI in addition to a review of all additional body systems, and complete PFSH

Accepted Answer

The CPT comprehensive history includes a chief complaint, an extended history of present illness (HPI), a review of systems (ROS) that covers all additional body systems, and a complete past, family, and social history (PFSH).

Question 2

Observation services furnished in a hospital outpatient setting where the patient is considered an outpatient __________.
A) are reimbursed when ordered by a physician
B) include a bed but no monitoring procedures
C) must be preauthorized by Medicare
D) routinely convert to an inpatient admission

Accepted Answer

Observation services in a hospital outpatient setting are reimbursed when ordered by a physician, as they are considered necessary for monitoring the patient's condition to determine the need for further treatment or admission.

Question 3

When the physician makes arrangements with other providers or agencies for services to be provided to a patient, this is called __________ of care.
A) coordination
B) delivery
C) quality
D) transfer

Accepted Answer

Coordination of care involves organizing patient care activities and sharing information among all participants concerned with a patient's care to achieve safer and more effective care.

Question 4

The CPT comprehensive examination includes a(n) __________.
A) extended examination of the affected body areas and other symptomatic or related organ systems
B) general multisystem examination or a complete examination of a single organ system
C) limited examination of the affected body area or organ system
D) limited examination of the affected body areas or organ systems and other symptomatic or related organ systems

Accepted Answer

The CPT comprehensive examination involves a general multisystem examination or a complete examination of a single organ system, as it is the most thorough level of examination.

Question 5

Which is an assessment of the patient's body areas and organ systems?
A) physical examination
B) review of systems

Accepted Answer

A physical examination is an assessment of the patient's body areas and organ systems.

Question 6

The CPT problem-focused history includes the __________.
A) chief complaint and brief history of present illness or problem
B) chief complaint, brief history of present illness or problem, and problem-pertinent system review
C) chief complaint, extended HPI, problem-pertinent system review extended to include a limited number of additional systems, and pertinent PFSH directly related to the patient's problem
D) chief complaint, extended HPI, ROS directly related to the problem(s) identified in the HPI in addition to a review of all additional body systems, and complete PFSH

Accepted Answer

The CPT problem-focused history includes only the chief complaint and a brief history of the present illness or problem.

Question 7

The CPT expanded problem-focused history includes the __________.
A) chief complaint and brief history of present illness or problem
B) chief complaint, brief history of present illness or problem, and problem-pertinent system review
C) chief complaint, extended HPI, problem-pertinent system review extended to include a limited number of additional systems, and pertinent PFSH directly related to the patient's problem
D) chief complaint, extended HPI, ROS directly related to the problem(s) identified in the HPI in addition to a review of all additional body systems, and complete PFSH

Accepted Answer

The CPT expanded problem-focused history includes the chief complaint, brief history of present illness or problem, and problem-pertinent system review.

Question 8

Subcategories of hospital inpatient evaluation and management services include observation or inpatient care services, which include the __________.
A) admission and discharge from observation/inpatient status on the same day
B) final examination of the patient, discussion of hospital stay with patient or caregiver, instructions for continued care, and preparation of discharge records, prescriptions, and referral forms
C) inpatient's first encounter
D) review of the chart for changes in patient's condition, results of diagnostic studies, and/or reassessment of patient's condition since performance of last assessment

Accepted Answer

Observation or inpatient care services include the admission and discharge from observation/inpatient status on the same day.

Question 9

CPT defines counseling as it relates to evaluation and management coding as a(n) __________ concerning areas that involve diagnostic results, impressions, recommended diagnostic studies, and so on.
A) assessment that impacts patient care
B) discussion with a patient and/or family
C) order for further ancillary testing
D) way to guarantee quality patient care

Accepted Answer

Counseling in the context of evaluation and management coding refers to a discussion with a patient and/or family about various aspects of their care, including diagnostic results and recommendations.

Question 10

Subcategories of hospital inpatient evaluation and management services include initial hospital care, which includes the __________.
A) admission and discharge from observation/inpatient status on the same day
B) final examination of the patient, discussion of hospital stay with patient or caregiver, instructions for continued care, and preparation of discharge records, prescriptions, and referral forms
C) inpatient's first encounter
D) review of the chart for changes in patient's condition, results of diagnostic studies, and/or reassessment of patient's condition since performance of last assessment

Accepted Answer

Initial hospital care refers to the inpatient's first encounter, which involves the initial evaluation and management services provided when a patient is admitted to the hospital.

Question 11

The CPT __________ of examination is categorized according to four levels.
A) extent
B) level
C) range
D) type

Accepted Answer

The CPT (Current Procedural Terminology) codes categorize examinations based on the extent of the examination, which refers to the thoroughness or comprehensiveness of the examination performed.

Question 12

Which is the amount of time the provider spends at the patient's bedside and at management of the patient's care on the inpatient unit or floor?
A) face-to-face time
B) unit/floor time

Accepted Answer

Unit/floor time refers to the total time a provider spends on the patient's care, including bedside and management activities, on the inpatient unit or floor.

Question 13

CPT medical decision making refers to the complexity of __________ as measured by the number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity or mortality.
A) assessing patient data in a group or single practice
B) completing a comprehensive history and physical examination
C) establishing a diagnosis and/or selecting a management option
D) ordering ancillary tests and interpreting their results

Accepted Answer

CPT medical decision making involves establishing a diagnosis and/or selecting a management option, which is assessed by the number of diagnoses or management options, the amount and/or complexity of data to be reviewed, and the risk of complications and/or morbidity or mortality.

Question 14

The CPT detailed examination includes a(n) __________.
A) extended examination of the affected body areas and other symptomatic or related organ systems
B) general multisystem examination or a complete examination of a single organ system
C) limited examination of the affected body area or organ system
D) limited examination of the affected body areas or organ systems and other symptomatic or related organ systems

Accepted Answer

The CPT detailed examination involves an extended examination of the affected body areas and other symptomatic or related organ systems, as opposed to a limited or general examination.

Question 15

The CPT expanded problem-focused examination includes a(n) __________.
A) extended examination of the affected body areas and other symptomatic or related organ systems
B) general multisystem examination or a complete examination of a single organ system
C) limited examination of the affected body area or organ system
D) limited examination of the affected body areas or organ systems and other symptomatic or related organ systems

Accepted Answer

The CPT expanded problem-focused examination involves a limited examination of the affected body areas or organ systems and other symptomatic or related organ systems, which is more comprehensive than a problem-focused examination but not as extensive as a detailed examination.

Question 16

Which is considered when determining the number of diagnoses or management options for medical decision-making complexity? It includes a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.
A) chief complaint
B) history of present illness
C) nature of presenting problem
D) review of systems

Accepted Answer

The nature of the presenting problem is considered when determining the number of diagnoses or management options for medical decision-making complexity. It encompasses the reason for the encounter, including diseases, conditions, symptoms, or complaints, regardless of whether a diagnosis is established.

Question 17

The CPT problem-focused examination includes a(n) __________.
A) extended examination of the affected body areas and other symptomatic or related organ systems
B) general multisystem examination or a complete examination of a single organ system
C) limited examination of the affected body area or organ system
D) limited examination of the affected body areas or organ systems and other symptomatic or related organ systems

Accepted Answer

A problem-focused examination is limited to the affected body area or organ system.

Question 18

The CPT detailed history includes the __________.
A) chief complaint and brief history of present illness or problem
B) chief complaint, brief history of present illness or problem, and problem-pertinent system review
C) chief complaint, extended HPI, problem-pertinent system review extended to include a limited number of additional systems, and pertinent PFSH directly related to the patient's problem
D) chief complaint, extended HPI, ROS directly related to the problem(s) identified in the HPI in addition to a review of all additional body systems, and complete PFSH

Accepted Answer

The CPT detailed history includes a chief complaint, extended history of present illness (HPI), a problem-pertinent system review extended to include a limited number of additional systems, and pertinent past, family, and/or social history (PFSH) directly related to the patient's problem.

Question 19

Subcategories of hospital inpatient evaluation and management services include subsequent hospital care, which includes the __________.
A) admission and discharge from observation/inpatient status on the same day
B) final examination of the patient, discussion of hospital stay with patient or caregiver, instructions for continued care, and preparation of discharge records, prescriptions, and referral forms
C) inpatient's first encounter
D) review of the chart for changes in patient's condition, results of diagnostic studies, and/or reassessment of patient's condition since performance of last assessment

Accepted Answer

Subsequent hospital care involves reviewing the patient's chart for changes, results of diagnostic studies, and reassessing the patient's condition since the last assessment.

Question 20

Which is the amount of time the office or outpatient care provider spends with the patient and/or family?
A) face-to-face time
B) unit/floor time

Accepted Answer

Face-to-face time is the amount of time the office or outpatient care provider spends with the patient and/or family.

Quiz 7: CPT Coding

The CPT comprehensive history includes the __________.

Observation services furnished in a hospital outpatient setting where the patient is considered an outpatient __________.

When the physician makes arrangements with other providers or agencies for services to be provided to a patient, this is called __________ of care.

The CPT comprehensive examination includes a(n) __________.

Which is an assessment of the patient's body areas and organ systems?

The CPT problem-focused history includes the __________.

The CPT expanded problem-focused history includes the __________.

Subcategories of hospital inpatient evaluation and management services include observation or inpatient care services, which include the __________.

CPT defines counseling as it relates to evaluation and management coding as a(n) __________ concerning areas that involve diagnostic results, impressions, recommended diagnostic studies, and so on.

Subcategories of hospital inpatient evaluation and management services include initial hospital care, which includes the __________.

The CPT __________ of examination is categorized according to four levels.

Which is the amount of time the provider spends at the patient's bedside and at management of the patient's care on the inpatient unit or floor?

CPT medical decision making refers to the complexity of __________ as measured by the number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity or mortality.

The CPT detailed examination includes a(n) __________.

The CPT expanded problem-focused examination includes a(n) __________.

The CPT problem-focused examination includes a(n) __________.

The CPT detailed history includes the __________.

Subcategories of hospital inpatient evaluation and management services include subsequent hospital care, which includes the __________.

Which is the amount of time the office or outpatient care provider spends with the patient and/or family?