Review Assessment: Coding Ambulatory

Quiz
User Steven Godelman
Submitted 10/2/09 11:51 AM
Name Coding Ambulatory Quiz
Status Completed
Score 10 out of 10 points
Time Elapsed 0 hours, 1 minutes, and 55 seconds out of 0 hours and 30 minutes allowed.
Instructions Please note the time when you open this assessment. You have 30 minutes to
finish; you will not be allowed extra time so please watch to make sure you do not go
over or you will be assessed a penalty for each minute you go over.

After your first attempt you will be taken to a page that will tell you your score. Also
you may check your score by clicking on Tools in the Course main menu and then
My Grades.
Question 1 1 out of 1 points
CC: Cough

HPI: 75-year-old male with porductive cough for five days, worse at night. Patient
also has fever and chest pain. Patient using cough syrup without improvement.

PH: Non-Smoker

ROS: Denies shortness of breath or heart palpitations.

EXAM: Vitals: temp 101.5, BP 140/80

ENT: Negative

Neck: Negative

Chest: Rhonchi bibasilar, pain on deep inspiration

CV: Negative

Abd: Negative

A/P: Acute bronchitis. Rx: Azithromycin, expectorant. Follow up as needed.

How many points is the history worth based on elements on the Trailblazer coding
sheet?
 Selected Answer: d.
5
Correct Answer: d.
5
Question 2 1 out of 1 points
Looking at the whole history, this should be considered a _______ History?

Selected Answer: c. Detailed

Correct Answer: c. Detailed
Question 3 1 out of 1 points
Based on the 1995 Guidelines, this exam should be considered a ______
Examination.

Selected Answer: c. Detailed

exam
Correct Answer: c. Detailed
exam
Question 4 1 out of 1 points
Using the Trailblazer reference Guide, what would the Medical Decision be in this
case?

Selected Answer: b. Low

complexity
Correct Answer: b. Low
complexity
Question 5 1 out of 1 points
What should this case be coded if this was an established office patient?

Selected Answer: c.
99214
Correct Answer: c.
99214
Question 6 1 out of 1 points
What should this case be coded if this was a new office patient?

Selected Answer: a.
99201
Correct Answer: a.
99201
Question 7 1 out of 1 points
 CC: Shortness of breath

HPI: 60-year-old female with emphysema and increased shortness of breath over the
past firve days. She uses albuterol and ipratropium three to four times per day,
which helps. Denies cough.

PH: Former smoker.

ROS: Denies chest pain or fever

EXAM: Vitals WNL

Chest: Poor air movement

CV: Normal

A/P: Emphysema with mild exacerbation. Requested chest X-ray, electrocardiogram

and complete blood count. Will switch her to inhaled tiotropium.

Assume this is an established office patient. Based on this patient's presentation,

what should be the Medical Decision Making Type for this patient?

Selected b. Number of Diagnosis 3 Points, Data 2 Points, Risk

Answer: Moderate=Moderate Complexity
Correct b. Number of Diagnosis 3 Points, Data 2 Points, Risk
Answer: Moderate=Moderate Complexity
Question
1 out of 1 points
8
In the above case, what type of History Type is shown?

Selected Answer: b. Expanded problem

focused
Correct Answer: b. Expanded problem
focused
Question 9 1 out of 1 points
In the above case, what type of 1995 Examination Type is shown?

Selected Answer: b. Expanded problem

focused
Correct Answer: b. Expanded problem
focused
Question 10 1 out of 1 points
Assume that this case documents Medical Decision Making. What are the missing
documentation elements that would allow the clinician to bill a CPT 99214?

Selected Answer: e. b and c

Correct Answer: e. b and
c