Health sciences and medicine
Medical Coding Test
1.How would you count the HPI elements in the below Hx?
2. Can you describe the different elements of HPI? How many are needed to code a 99284 chart?
3. What documentation is needed in ROS to code a 99285?
4. What Organ System does the following documentation count for: “Head is normocephalic; atraumatic”?
5. For billing purposes, what documentation could be done by a Student?
6. When billing for procedures with resident involvement, what needs to be documented & who needs to document it?
7. What needs to be documented to bill an EKG interpretation? To Medicare?
8. What documentation is required to bill with Scribe involvement according to any CMS carrier (pick one & cite)?
9. What documentation areas in either Emergency do you think are underdocumented most frequently?
10. What documentation is required to bill Critical Care Time?
11. Can ED providers bill for Straps and Splints? If so, what are the basic requirements and is it carrier specific?
HOSPITALIST CODING ANALYST QUESTIONNAIRE
1. How many areas of PFSH are required to be documented for a comprehensive history for a patient on an inpatient status? How is it different to the PFSH documentation requirement in the emergency department?
2. The documentation requirement for an initial visit for a patient that was admitted in an inpatient status is different for initial consult service. True or False? Explain.
3. What do we mean when face to face encounter documentation is required on documentation? Can a discharge summary be reported for service without this?
4. How many organ systems are recognized on Review of systems? How is this different with the organ systems recognized on the physical exam? How many organ systems are required for a comprehensive exam?
5. Can we count a body area examination for a comprehensive examination? Can we combine body area and organ systems for a physical exam on a follow up visit? Explain.
6. What is the difference between the documentation requirements for an initial visit versus a follow up visit? Are all three key components required for all these services?
7. For a resident documentation, is an attestation required when a patient was not seen and examined by the attending physician? Explain
8. Can a midlevel provide an attestation on the supervising physician’s behalf when the supervising physician has seen and examined the patient? Explain.
9. When a provider cannot retrieve a patient’s history because of the patient condition, do we give them credit for comprehensive history when the reason is not documented? Explain.
10. Would the provider’s assessment listed below be sufficient for a high complexity medical decision making? Explain.
Assessment:
1. Hypertension,
2. Diabetes,
3. Chest Pain,
4. Pneumonia