EM Practice Exam Question — Medical Coding Training http://www.cco.us/ceu-em-on-demand-classes-yt
This was one,actually, I got twice this week so I said alright. There’s a practice exam out there, I won’t say where. I reworded it so I don’t get in trouble. But two different people emailed me about it. So I said, “Okay, I’m going to go over this.” So here’s the question: A 60-year old woman comes in for a second opinion for her sleep apnea. The physician documents an extended history. She’s had it for the past 4 months. Sleep is disrupted by frequent awakening and getting worse by anxiety and snoring. Current medication that she is now on is not helping. An extended review of systems indicate she feels tired all the time, has some joint stiffness and night sweats. She is going through a divorce. Doctor performs a comprehensive exam and moderate medical-decision making.
So this is from students who have either taken my Blitz or the course and I teach a method, Locate your HEM in time which basically is saying… well first, identify the location or the category and subcategory of E&M. And in this case, the answers are 99203 and 204 which are office new patient codes. And then 214 is an established and 243, I think, is a consult. So because they’re coming in for a second opinion, we can cross off C and D. Okay so it’s now going to be 203 or 204 and that’s the tie breaker that we want to try and figure out.
So here’s my little worksheet. I tell you to write on your exam booklet or even in the real coding world, on your you know, whatever… wherever you’re keeping notes, Locate and HEM. And the goal is to fill in the blank to the right. So for location, we’ve identified it as office new.
For the history, they didn’t really come out and give us the history which often times, in the board exam, they will do. But it did say the physician documents an extended history. Well, for history and exam, they have problem-focused, expanded problem-focus, detailed and comprehensive. So extended isn’t one of those terms. So they technically did not provide outright with the overall history level is. But for exam, they did. They said comprehensive exam and moderate medical decision-making. So I put a C for the exam and I put an M for moderate decision making for the medical decision making.
Now when you look in your CPT book, in the E&M section for office new, you’d see that the C shows up on the level 5 or 99205. So for shorthand, we just put a 5. And the moderate medical decision making shows up at a level 4. So so far, these are the two levels. We need to figure out what the history is because for office new, we know that we need to meet or exceed all 3 of the bullets for that exam.
So what this is doing is it’s making us work for the history. So for the history since we have to work for it, we need to turn to our history table that you hopefully wrote in your manual. And you know what? Let me see if I can get my document camera up for that.
Alicia: While she’s doing that, I was going to mention, this is classic for board exams. They’re wanting you to… they know you know how to find codes but can you pick the right code? By having to come up with the history, that shows them that you know how to pull the history out of your documentation and pick the correct code.
Laureen: Okay so this is my page 3 of my CPT manual which you know, if you do the Blitz or the course, you’ll get a copy of this. This is what you want to write in your worksheet and we’re trying to fill in these blanks. Okay, that’s what I’m trying to do on the slide. So since we’re trying to figure out history, I’m going to go to the history table that I wrote in and this is basically taking the… let me back up here just a little bit.
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