Hospitalist E/M Coding Explained – Part 2 This webinar is AAPC-approved for 1.0 CEU. Can be used for Core A 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 Hospitalist Medicine Provider Documentation and Coding 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 NameEmailIn Hospitalist practice, a Comprehensive History is required to bill Initial observation and inpatient codes. A Comprehensive History consists of: Documentation of 1 to 3 elements of HPI, 2 to 9 systems in ROS, and 1 comment related to Past, Family, or Social History Documentation of 4 elements of HPI, 10 or more systems in ROS, and one comment related to each of Past, Family, and Social Histories Documentation of 1 to 3 elements of HPI, 1 system related to problem in ROS, and no documentation of Past, Family and Social Histories Documentation of 8 Exam areas or systemsIn Hospitalist practice, a Comprehensive Exam is required to bill Initial observation and inpatient codes. A Comprehensive Exam consists of: Documentation of 2 to 7 Exam areas or systems Documentation of 2 to 7 Exam areas or systems with an extended Exam of the affected area or system. Documentation of 1 Exam area or system. Documentation of 8 Exam areas or systems.True or false: In Hospitalist practice, when coding subsequent visit codes, documentation of all 3 of the 3 key elements of Evaluation & Management Coding are required. True FalseIn Hospitalist practice, initial hospital visits require which of the following: Documentation of a detailed interval history or exam PLUS a significant complication. Documentation of a Comprehensive Exam only. Documentation of a Comprehensive History and Exam. Documentation of AN expanded problem focused interval history OR exam PLUS a minor complication.Documentation deficiencies in HPI regularly result in down-codes. Which of the following code sets always requires 4 elements of HPI? Subsequent observation codes 99224 - 99226 Discharge codes 99238 and 99239 Subsequent visit codes 99231 - 99233 Initial visit codes 99221 – 99223True or false: Interval histories are acceptable for subsequent visits but only for HPI and PFSH. ROS needs to be re-documented. True FalseE/M Code 99238 should be used to indicate discharge services totaling: Greater than 74 minutes. Greater than 30 minutes. Code 99232 is not a discharge services code. 30 minutes or less.Fill in the blanks: A patient who qualifies for application of subsequent observation care code 99226 would generally be described as unstable or as having developed a significant complication or new problem. Proper use of this code requires documentation of a ______ history __ a _________ exam, and an MDM of _____ complexity. a detailed history OR a detailed exam, and MDM of high complexity a detailed history AND a detailed exam, and MDM of high complexity a comprehensive history OR a comprehensive exam, and MDM of high complexity a comprehensive history AND a comprehensive exam, and MDM of high complexityWhich of the following is NOT required to code observation care discharge code 99217, which is used to indicate that a patient was admitted for observation care and then discharged on a different calendar date: Final patient exam and discussion of hospital stay Instructions for continuing care to other care givers Time Preparation of discharge records, prescriptions, and referral formsIn which of the following instances is documentation of time NOT important: When providing discharge services for an inpatient When providing discharge services for a patient who was admitted for observation and then discharged the following day. When providing Critical Care Services. When providing counseling or coordination of care.