Coding Corner Question

Evaluation and Management Components

Can you and your coding or billing staff pass this quiz?

1. If a patient comes in with two established problems that are worsening, what is the level for the number of diagnoses or treatment options?
   1. Minimal
   2. Limited
   3. Multiple
   4. Extensive
   5. None of the above
2. A chief complaint must be listed in the patient’s medical record for each visit.
   1. True
   2. False
3. How many elements are needed for an extended history of present illness (HPI)?
   1. One
   2. Two
   3. Three—or the status of at least three—chronic or inactive conditions
   4. Four
   5. Four—or the status of at least four—chronic or inactive conditions
4. What is needed to achieve a comprehensive history level for a new patient?
   1. Chief complaint (CC), extended HPI, extended review of systems (ROS), no past family and social history (PFSH)
   2. CC, brief HPI, extended ROS, no PFSH
   3. CC, extended HPI, complete ROS, two of the PFSH
   4. CC, extended HPI, complete ROS, three of the PFSH
   5. None of the above
5. If a patient is diagnosed with an acute or chronic illness that may pose a threat to life or bodily function, such as severe rheumatoid arthritis (RA), what level of risk would this be?
   1. Minimal risk
   2. Low risk
   3. Moderate risk
   4. High risk
   5. None of the above

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