EM Practice Exam Question — Medical Coding Training


Alright so Iím going to take this first question.
This was oneÖ actually, I got twice this week so I said alright. Thereís a practice
exam out there, I wonít say where. I reworded it so I donít get in trouble. But two different
people emailed me about it. So I said, ìOkay, Iím going to go over this.î So hereís the
question: A 60-year old woman comes in for a second opinion for her sleep apnea. The
physician documents an extended history. Sheís 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
sayingÖ 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 theyíre coming in for
a second opinion, we can cross off C and D. Okay so itís now going to be 203 or 204 and
thatís the tie breaker that we want to try and figure out. So hereís my little worksheet. I tell you
to write on your exam booklet or even in the real coding world, on your you know, whateverÖ
wherever youíre keeping notes, Locate and HEM. And the goal is to fill in the blank
to the right. So for location, weíve identified it as office new. For the history, they didnít 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 isnít 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, youíd 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 itís 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 sheís doing that, I was going
to mention, this is classic for board exams. Theyíre wanting you toÖ 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, youíll get a copy of this.
This is what you want to write in your worksheet and weíre trying to fill in these blanks.
Okay, thatís what Iím trying to do on the slide. So since weíre trying to figure out
history, Iím going to go to the history table that I wrote in and this is basically taking
theÖ let me back up here just a little bit. Alicia: I want to say I think you can make
it smaller. Laureen: Yeah, thatís what Iím doing. Howís
that? Alicia: Perfect. Laureen: Okay so Iím a very visual person
as youíve heard me say many times before, if youíve listened to me on these videos
because when I see paragraphs of text, itís like Charlie Brown. Iím just not getting
it. So I have to convert things to a visual. So all of this table is from the guidelines
in the pages that preceed this. So I just took history present illness, I turn to the
definition for HPI and I saw that there were 2 possible scores. Okay, you see that extended
so that should look familiar. So an HPI, history present illness can be either brief or extended.
Well, they told us it was an extended, right? Okay so the next piece of history is review
of systems. And you can have no review of systems done. You can have a problem pertinent
which is basically one system, problem pertinent thatís extended, that 2 to 9 or complete
which is 10 to 14 systems. Now, review of systems sounds a lot like the exam because
youíre talking about cardiovascular, genito-urinary. So it sounds like things that you would examine.
But itís what I call the talking, not the touching. It sounds a little perverted but
theyíre asking the questionÖ the patient questions about those organ systems because
itís something that they canít measure or palpate or you know, weigh. They have to find
out you knowÖ. well you know, are you having headaches too? You know, that kind of thing.
They canít look at you and see that youíre having a headache. You have to tell them. And then the 3rd piece to history is the past
family social history or someone recently said, ìOh PFSH.î Like okay, whatever works.
But thereís 3 distinct pieces, past history, family history and social history. So if you
see documentation for one or two of those, itís considered a pertinent PFSH. All 3,
itís considered a complete. And then hereís the 4 possible levels that
we want to fill in on our H line down here, P E D C ñ problem-focused, expanded-problem
focused, detailed or comprehensive. Okay so theyíre making us work for it on the slide,
let me go back there real quick. Are you still seeing my book or are you seeing the slide? Alicia: Yeah, weíre seeing the book. Laureen: Oh okay. How about now? Alicia: There we go, back to the slide. Laureen: Okay soÖ there we go. So the HPI
is extended. The ROS was extended. The past family social history is pertinent because
when you read about it, it was just really talking about sheís going through a divorce.
Okay so when you go back to the table, weíre trying to plug in, extended, extended pertinent.
And the extended weíll see will come out to a C. The extended ROS comes out to a D
and the pertinent comes out to a D. So letís see how that works out. Extended, extended,
pertinent. Alright so hereís extended, hereís extended and hereísÖ thatís not what I
was looking for. What did I say? One of them came out to a C. Oh okay, here we go. So since extended on this one, it shows up
on both levels, we always give them a higher one. We always give them the most credit that
we possibly can that they document it. So thatís why the HPI is going to get a C. Okay
but the extended for ROS only shows up at this row so they get a D and then the pertinent
gets a D. And when you put that all together, since this is a 3 of 3 table, the lowest wins.
And the lowest in this case is going to be the detailed. Alright? So now we come along and now we canÖ where
we had not provided out right, we figured it out. Itís a D, itís a detailed. And when
we turn to the 99203 and 4 code, we can see when itís 3 of 3, we code to the lowest.
So whatís the lowest between a level 3, 4, and 5? The level 3. Okay so the answer to
this case is 99203. The reason this kept coming to me is they had it wrong in the answer key.
They were telling them it was B or it was 99204. So thatís where the confusion was
coming and they thought they were doing this pattern correct but how they tricked them
was they used this extended history. And theyíre thinking, ìOh, E-extended.î But itís actually
expanded problem-focused history. So you had to go back and really look at it closely and
use that table. So for those who havenít taken their certification
exam, the heads up for you is that it used to beÖ thereís about 10 questions on E&M
on the board exam. About 2 of the 10, I used to say, they make you work for it. Now Iím
hearing itís more like 4 to 5 of the 10. So definitely make sure you write your tables
in and your CPT manual so you can use them to help you figure out the missing slot. Get more cpc exam tips, coding certification
training, and ceu credits. Go to http://www.codingcertification.org

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