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Test Your Auditing Knowledge

Multiple Choice

1.

Using 97 guidelines, what would be the level for this examination?

PHYSICAL EXAM: Weight 172 lb. BP 128/78 P 72. In general she is a well developed well nourished white female. HEENT: Eyes are round and reactive to light and accommodation. Neck – supple. No adenopathy or thyromegaly. Heart RRR without murmur, rub or gallop. Lungs – clear to auscultation bilaterally. Abdomen – soft. She has some diffuse tenderness to palpation, but this is mild. Extremities no cyanosis, clubbing or edema. EKG was normal. Pulse ox normal. Urine dip and Hematocrit are normal.

a. Problem Focused

b. Expanded Problem Focused

c. Detailed

d. Comprehensive

2.

Using 97 guidelines what is the level of visit for this patient?

Chief Complaint: Follow-up visit of pneumonia

S:
This child is here to recheck from an emergency room visit. She was diagnosed with pneumonia in the left anterior chest. She was put on Zithromax and she took Albuterol for a day and has not been on it since then. She perked up and is doing much better. She has some cough and a little bit of wheezing but not much. Mother is concerned about the possibility of asthma due to their family history of asthma. Denies vomiting or fevers.

O:
She’s real active and breathing fine. HEENT: normal. Neck: supple. Lungs show a few rales in the left anterior chest. She’s not wheezing. She’s moving air fine.

A:
1. Pneumonia, left upper lobe

P:
Finish up the Zithromax, use Albuterol as needed. Allow this to gradually clear over the next few weeks. We may want to have an evaluation for asthma since this is her second episode this year for breathing related emergency visits. Continue using either the syrup of Proventil if needed. I want to evaluate the patient again in two weeks. Dr. Mark Smith

a. 99212

b. 99213

c. 99214

d. 99215

3.

Chief Complaint: Sore Throat

S:
This 44 year old established female patient that presents today complaining of sore throat. It started three days ago and has some hoarseness as well. She says it hurts to swallow and feels like she is swallowing glass. She is presently on 10 mg of Ambien, and Cerefolin NAC, 600 mg which were previously prescribed by me. The patient complains of sore throat, hoarseness, negative for chest pain, chills, diarrhea or constipation, painful urination, fever, back pain, shortness of breath, difficulty breathing, vision problems, easy bruising, rashes or mood swings. No change in past medical, family or social history since last visit of 4/3/10 that I personnally reviewed with the patient.

O: Weight: 187, Temp: 99.2. This is a pleasant, 44 year old female who looks his given age, is well—developed and nourished with good attention to hygiene and body habitus. Psychiatric exam reveals orientation x 3 with mood and effect appropriate to situation. Eyes are reactive to light and accommodation, conjunctivae are without signs of infection. Inspection of external ear reveals no gross abnormalities, no discharge or external signs of infection. Otoscopic examination reveals clear external auditory canals with no evidence of bulging, erythema in the tympanic membranes. Inspection of lips, gums and palate reveals healthy gums, lips and palate pink and moist without lesions. Examination of oropharynx reveals erythema, and postnasal drip. Respirations are even without use of accessory muscles and no intercostal etractions noted. Lungs clear to ausculation. Heart regular rate and rhythm. Extremities are warm to the touch, and edema is not observed. No clubbing, or cyanosis. No skin rash, subcutaneous nodules, lesions or ulcers observed. No test results to report at this time.

A:
Viral sore throat, recommend salt water gargles. QuikStrep: negative for beta streptococcus group A. Specimen sent for Strep culture

P:
Mrs. Doe was counseled on the following topics. Resting as much as able. Taking medications as previously prescribed. Drinking plenty of warm liquids, avoiding caffeinated drinks as much as possible. Using OTC Tylenol or Motrin according to package instructions for fever greater than 101.0 or for aches and pains. She is to follow-up in the next 7 to 10 days if she is not feeling any better or sooner if she is doing worse. Tommy Smith, MD

Using 97 guidelines, the doctor charged a 99214. What level does this documentation support?

a. 99212

b. 99213

c. 99214

d. 99215

4. The patient is positive for fever and chills. Complains of some generalized shortness of breath and chest tightness. He denies chest pain, palpitations, hematemesis or any blood in his stools or dark tarry stools but has had significant diarrhea since his chemotherapy started. Denies dysuria or hematuria. He has had some increasing joint pains as well as diffuse weakness. No rashes or other lesions. No focal weakness, numbness or tingling. No excessive sweating. How would documentation of the Review of Systems be scored?

a. None

b. Pertinent to 1 system

c. 2-9 systems

d. 10 or more systems

5.

S: Gary Nelson comes in for an initial office visit with his 14 month old daughter Tara, who has persistent diarrhea. The family has just moved here from out of state.Mr. Nelson is frustrated because she’s had the diarrhea continuously for the last month and always seems to be sick. She also has a history of ear infections. He is requesting either more complete work-up on his daughter or to be referred to a specialist. Tara is constantly congested and I suspect she may have an allergy to milk because of the diarrhea and congestion. Her weight has not changed but she is teething. She has also been tugging at her ears

O:
Temp: 101.1 She is smiling and playful but does appear pale. TM's are both red and inflamed. Oral pharynx show mucous. Abdomen is soft and normal bowel sounds. Lungs are clear. RRR normal.

A:
Diarrhea, Otitis Media, URI and possible milk intolerance

P:
I am recommending to temporarily get some acidophilus at the health food store, to be used in place of milk. I also explained this will help replace the flora in her intestine which have been killed as a result of the antibiotic therapy and that should cut her diarrhea. If the diarrhea persists after making this change, I told Mr. Nelson I would then refer them to a Pediatric Gastroenterologist. I have also requested that they obtain a stool specimen and bring it into the office for further testing. I will also set up a GI ultra sound. Patient is to follow-up with me one week after the ultra sound. We are also requested records from previous peditrician.

What is the level of the MDM for this visit?

a. Straightforward

b. Low

c. Moderate

d. High

6. According to 95/97 documentation guidelines which of the following can be recorded by the ancillary staff or form completed by the patient but must be reviewed and confirmed by the physician the information that was recorded by others?

a. HPI, ROS, PFSH

b. HPI, ROS

c. ROS, PFSH

d. HPI, PFSH

7.

What is the History for the following note?

Chief Complaint: Cough and Rash


Patient has had a cough for the last week. Initially it was dry. It has been loosening up and and he did have a fever last night. He woke this am again with the fever and a rash that covered his whole body in a lace like pattern primarily to the extemities, abdomen and chest. There was no rash on his back and it did not itch. He tried taking Benadryl but it only made him sleep and the rash was still present. He denies any shortness of breath, congestion, runny nose, chills, sweating. He had had some dizzy spells and a sore throat but it is not severe. He does have a history of sinusitis and continues to smoke.

a. Problem Focused

b. Expanded Problem Focused

c. Detailed

d. Comprehensive

8. Choose the answer that would be an example of a physician signature that would not meet the Medicare requirements:

a. Provide a legible first initial and last name

b. Write initials over typed or printed name

c. Use an illegible signature accompanited by a signature log or attestation statement

d. Illegible signature without a typed or printed name

9. What is the level of this visit using 95 guidelines?

Chief Complaint: Gout attack and shortness of breath

Patient comes in with complaints of right hand swelling due to acute gout attack and some shortness of breath. The shortness of breath is something that she reports slowly comes on. She believes the symptoms started when she began Meridia but is not sure. In terms of her gout, she tells me she started eating cherries and those apparently have some homeopatic effect and actually have helped somewhat. She denies chest pains.

Patient is a very large woman. Pulse ox is 90% on room air. Breath sounds are distant yet clear and I do not hear any rales. Heart has RRR. Right hand exam reveals swelling.

1. Shortness of breath
2. Acute gout

Patient will discontinue Meridia. We will draw a Uric Acid level today. She is to see how she does this week-end without Meridia and will need to follow-up with me next week.

Mark Twig, MD 3/23/2010

a. 99212

b. 99213

c. 99214

d. 99215

10. Which answer below is not required for an operative note?

a. Pre-op/Post-op diagnosis, surgeons, any complications, patient name and date of birth

b. Date of surgery, surgical approach, instruments and supplies used, anesthesia used

c. Procedure performed, condition of patient after procedure, consents obtained

d. All of these are required

 

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