Coding Corner: Evaluation and Management

1. There are four components to an evaluation and management visit. Which one should drive the visit?

1. Chief complaint
2. History
3. Examination
4. Medical decision making

2. The term “follow-up visit” can be listed as the chief complaint in a patient’s medical record.

1. True
2. False

3. The history of present illness documentation in a patient’s chart indicates two stable chronic diseases. What does that equate to for the number of diagnosis or treatment options under the medical decision making?

1. Minimal
2. Limited
3. Multiple
4. Extensive

4. What is a cloned note?

1. A photo copy of a note
2. The electronic version of the note
3. A bad movie
4. The cutting and pasting of information entered in an electronic health record (EHR) from a past visit

5. A practice is safe from being audited for cloned notes because the EHR chooses the code.

1. True
2. False

Click here for the answers.