Sections of the chart
Rads and monitoring
Procedures
Medical Terminology
Signs/Points
100
Pt has a h/o HTN and occasionally smokes but never drinks. This is an example of level __ billing for which chart section? Why?
What is level 5 billing of PMFSHx? (2 elements; medical history and social history)
100
These must be documented for pulse ox.
What is (1) the value or % oxygen, (2) type of oxygen, and (3) interpretation?
100
Regarding billing requirements, these must be documented for a splint.
What is (1) the location of the splint, (2) the type of splint, (3) who applied it and (4) reassessment of NV status by provider?
100
This means nearer to the front of the body.
What is anterior?
100
When +, this indicates potential abnormality of the gallbladder associated with acute cholecystitis. It is located in the RUQ.
What is Murphy's sign?
200
Pt presents to ED c/o SOB. This is the PE: General: No acute distress, alert Skin: Warm, dry, intact Eye: PERRL, EOMI, nml conjunctiva ENT: dry mucous membranes, clear TM, pharyngeal erythema Cardiovascular: Sinus tachycardia, 2/6 systolic murmur, pedal edema Respiratory: lungs are clear, breath sounds are equal, no wheezes Back: nontender, nml alignment, no step-offs Neuro: A&Ox4, CN 2-12 intact Psyc: cooperative, appropriate mood and affect This PE bills at level __ because...
What is level 5 billing of PE? 9 body systems with 2 findings for each and 3 for system of CC.
200
These must be documented for EKGs.
What is (1) rate and rhythm, (2) interpreted by me and (3) 3 +/- findings?
200
Regarding billing requirements, these must be documented for intubation.
What is (1) preparation, (2) blade, (3) tube and procedure, (4) medication, (5) result and (6) performed by?
200
This means coughing up blood.
What is hemoptysis?
200
This is the name given to the point on the body over the RLQ between the belly button and right hip.
What is McBurney's point?
300
ROS: HA, dizzyness, tinnitus, petechiae, numbness, icterus, sore throat, and pruritis. No cough or numbness. This ROS would bill at level ___ because...
What is level 4 billing of ROS? 5 body systems= Neurologic, ENT, skin, eye, respiratory
300
CXR shows nml mediastinum and cardiomegaly. Interpreted by me. Does this bill? Is anything wrong with this?
No. Missing # views and needs 1 more finding.
300
These are the billing documentation requirements for CPR.
What is (1) time started and stopped, (2) rhythm, pulse, (3) medication and time given and response to meds, (4) total time of CPR?
300
This means rapid breathing.
What is tachypneic?
300
This is when pressure applied to the LLQ increases pain in the RLQ. It indicates ____________.
What is Rovsing's sign, indicating appendicitis?
400
CXR ordered and documented, EKG ordered and documented, CT (chest) ordered and documented, and discussed CT and CXR results with radiologist. This is an example of level ___ billing for which chart section? Why?
What is level 4 billing for MDM? (1) radiology (2) EKG and (3) discussed CT/CXR results with radiologist.
400
CT shows no ICH and midline shift to R 1.25 cm. Interpreted by me. No acute disease. Is anything wrong with this?
Yes. Missing type of CT (head). EDMD can't interpret CTs so it should say "Interpreted by radiologist" and "Reviewed by EDMD".
400
Regarding billing requirements, these must be documented for laceration repair.
What is (1) anatomical location, (2) length, (3) complexity, (4) anesthesia, (5) preparation, (6) irrigation? (7) type of suture and method of closure (8) # of sutures, and (9) post procedure evaluation?
400
This means partial or complete collapse of the lung.
What is atelectasis?
400
This is when the patient sways or falls when their eyes are closed and they are standing up, indicating ________.
What is Romberg's sign? Indicating either neurological problem or that they are drunk.
500
I need 4 elements to bill at level 5.
What is the # of elements needed billing for Level 5 HPI and MDM?
500
These must be documented for a bedside US or FAST US.
What is (1) indication, (2) views, (3) interpretation, (4) performed by, and (5) interpreted by?
500
Regarding billing requirements, reduction, debridement, I&D and wound repair all require this to be documented.
What is the type of analgesia/sedation or anesthesia used?
500
This means bright red blood in the stool.
What is hematochezia?
500
This is when forced flexion of the neck elicits reflex flexion of the hips, indicating _____________.
What is Brudzinski's sign, indicating meningitis?
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