2023 Evaluation and Management Service Guidelines – Emergency Medicine Coder Training – Part 3 of 4 This webinar is AAPC-approved for 1.0 CEU and/or CEDC, and all specialties except CIRCC and CASCC provided you score a 70% or higher on the post test. Test takers should read all test instructions, and complete the Required Information fields at the top of the test. This test consists of 10 questions. Please select one best answer for each test question by clicking on the square next to the answer you have selected. This test is not timed; however, the test must be taken in one sitting. When all 10 questions have been answered, please click on the Submit Test button. Your score, as well as logic-reach reasoning for answers to any test questions that you missed, will be displayed immediately following completion and successful transmission of this test. For technical support for your Emergency Medicine Coding and Reimbursement Webinar Library subscription please call or email: Cari Laplace Webinar Technical Support Administrator BSA Healthcare Phone: 1-561-434-4740 Email: claplace@bsanda.com NameCompany NameEmailTrue or False: The “Data” component of the MDM Table consists of three categories. Category 2: Independent Interpretation of Tests, includes the ED providers’ independent interpretation of any labs, x-rays, and special studies that they order in the course of a patient encounter as well as any CXRs, CT scans, Ultrasounds, and/or MRIs that are interpreted by a radiologist. True FalseWhich of the following is NOT true with regards to analyzing the results of any tests that are ordered: Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. Additional future results, if analyzed in a subsequent encounter, may not be counted in that subsequent encounter. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. Tests ordered are presumed to be analyzed when the results are reported. When they are ordered during an encounter, they are counted in that encounter.Which of the following in NOT true of an independent historian? An independent historian is an individual (e.g., parent, guardian, surrogate, spouse, witness, caregiver) who provides a history because the patient is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary. Translation services will not be provided to an independent historian. An independent historian must provide the independent history during a face-to-face encounter with the treating provider. The independent history does need to be obtained directly from the historian providing the independent information.Which of the following is true regarding discussion or management of test interpretation? The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The exchange does not need to be in person. All the above.With regards to discussion or management of test interpretation, which of the following does NOT qualify as an external physician or other appropriate source? Professionals who are not health care professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). Family. Informal caregivers. B and C.Which of the following is true about a “unique source”? A unique source is a physician or other qualified health care professional in same group or the same specialty or subspecialty. A unique source is a physician or other qualified health care professional in a distinct group or a different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM. B and C are both true of a unique source.In “Data” Category 1: Tests & Documents/Independent Historian, each unique test, order, or document from each unique source is individually counted to meet the indicated requirement for each level of Data. A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed with review of each garnering one point. Given this, how many points would be garnered for a review of a discharge summary from a prior inpatient stay and review of nursing home records? One point Two points Three points No points.True or False: “Assessment requiring an independent historian” always counts towards Data Category 1: Tests & Documents/Independent Historian? True. False.In order to qualify as “limited,” data review must meet the requirements of at least one of the following two categories: Category 1: Tests & documents or independent historian(s) and Category 2: Independent interpretation of tests. Category 2: Independent interpretation of tests and Category 3: Discussion of management or test interpretation. Category 1: Test & documents and Category 2: Assessment requiring an independent historian(s). Category 1: Tests & documents or independent historian(s) and Category 3: Discussion of management or test interpretation.Fill in the Blank: In order to qualify as “extensive,” data review must meet the requirements of at least _____ out of the following three categories: 1. Category 1: Tests, documents or independent historian(s); 2. Category 2: Independent interpretation of tests; or Category 3: Discussion of management or test interpretation. 1. 2. 3. 4.
