Coding Corner Question: Evaluation & Management Documentation Quiz

Evaluation & Management Documentation Quiz

1. What element drives an evaluation and management (E/M) visit?
   1. The chief complaint in the patient’s own words of why he or she is in the practice for that date of service.
   2. The presenting problem(s) being discussed with the physician for that patient during the visit.
   3. The examination performed on the patient.
   4. The history of the patient taken during the visit.
2. Medical decision making is the same as medical necessity.
   1. True
   2. False
3. An established patient is seen in the practice, and the provider documents a comprehensive history, comprehensive examination and medical decision making (MDM) of low complexity. Should this scenario be coded as a Level 5 visit?
   1. Yes
   2. No
4. What is the key difference between 1995 and 1997 guidelines?
   1. The history
   2. The examination
   3. The medical decision making
   4. All of the above
5. What are the key components that should be included in the physician’s documentation of a patient’s encounter?
   1. Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results
   2. Assessment, clinical impression or diagnosis
   3. Medical plan of care
   4. All of the above

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