The number of billable elements required for the HPI to hit "Level 5" billing?
What is four?
There are a total of eight billable elements: location, severity, timing, onset/duration, context, modifying factors, associated symptoms, and quality
100
The medical term for gallstones is spelled?
What is cholelithiasis?
100
If concerned for a PE, this radiology study would be ordered.
What is chest CT?
100
Scleral icterus would go under which section in the physical exam?
What is Eyes?
100
The surgical term for the removal of the uterus
What is hysterectomy?
200
This post check is required in order to bill for a splint
What is a neurovascular recheck?
You must have a neurovascular recheck comment in addition to commenting on the type of splint placed and its location
200
An umbrella term for an irregular heart rhythm is spelled...
What is arrhythmia?
200
A patient presents with RUQ abdominal pain, fever, and nausea. The pain is exacerbated by eating greasy foods. Upon examination, the patient is noted to have a positive Murphy's sign. These symptoms are most concerning for?
What is Cholecystitis?
200
"Ketones on the breath" would go under this section of the physical exam
What is Constitutional?
200
The word cachectic belongs in this physical exam section
What is Constitutional?
300
This procedure is typically used when a patient presents with an abscess
What is an Incision and Drainage (I & D)
300
The medical term for a nose bleed is...
What is epistaxis?
300
Three pillow orthopnea is concerning for?
What is congestive heart failure (CHF)?
300
"JVD" would be found in this section of the physical exam
What is Neck?
Jugular Vein Distention. Cardiovascular is acceptable in some documentation records
300
Poor R wave progression and Right Axis Deviation would be found on this diagnostic ED test
What is Electrocardiogram (EKG)?
400
This caveat would be appropriate to use for a Spanish speaking patient with a history of dementia
What is "limited due to dementia or confusion?"
400
The acronym ICH stands for and is spelled?
What is Intracranial Hemorrhage?
400
Leg swelling and dyspnea are symptoms of these TWO differentials
What is a PE and CHF?
Note: Unilateral leg swelling is more concerning for PE/DVT
400
A "pulsatile mass" would likely go under this section of the physical exam
What is Abdomen/GI?
400
Dyspepsia describes this symptom and should be placed in this section of the chart
What is indigestion and ROS?
500
A very critical patient presents in active STEMI and it admitted immediately to the ICU after 23 minutes in the ED. The amount of critical care time this patient's chart would bill for is?
What is 0 minutes?
This does not meet the minimum time requirement to bill for critical care.
500
If untreated, a UTI may tern into this term.
What is pyelonephritis?
500
Elevated creatinine and a concern for PE would indicate that this test be ordered
What is a VQ Scan?
500
A positive Babinski's sign would go under this section of the physical exam