Auditing 101 1.a.Patient complains of right shoulder painb.Patient has SOB on exertion c.Patient c/o hematuria for the past 3 daysd.Patient complains...

Question Answered step-by-step Auditing 1011.a. Patient complains of right shoulder painb. Patient has SOB on exertion c. Patient c/o hematuria for the past 3 daysd. Patient complains of sore throat with fevere. Patient is here to follow-up on hypertension, asthma and diabetes. All conditions are stable and doing well on medication. 1.Which of the following statement include location as and HPI element? _______2.Which of the following is a statement of 3 chronic conditions? ______3.Which of the following is a statement of duration as and HPI element? ___________4.Which of the following is a statement of associated sign and symptom as and HPI element? _________5. Which of the following statement include context as an HPI element? ___________________2. Patient is here to follow-up on COPD, hypertension, and hyperlipidemia all are stable and patient doing well. This is an example of status of three ongoing medical conditions. True or False.3. Patient is alert and oriented, well-nourished white female. Blood pressure is 124/82 and she states her weight is 260 pounds. Conjunctivae are clear. Heart is RRR, lungs are clear. No lymphadenopathy. Abdomen is soft with normal bowel sounds, no HSM. Extremities without edema; pulses are strong. How many organ system would be counted using the 1995 exam criteria? _____4. If the physician wants to code 99239, he needs to indicate what.___________________________5. Three hours of critical care would be coded as ______________________________________6. The physician documents that she spend 40 minutes with an established patient and documents she counseled the patient regarding a new diagnosis and management options. She counseled for 20 minutes. What code would you bill out? A. 99202b. 99215c. 99214d. 99203e. 992057. 7. Vitals: BP 120/40 P 62, R 16 ENT: Normal Lungs: Clear Heart: Regular Abd: Soft What level would you give the exam if using the 1995 exam? PF – EX PF – Detailed – ComprehensiveStudies1. Patient complains of chest pain, which began three hours ago. Pain has been off and on since that time with each episode lasting two to three minutes. The pain is described as crushing and at times is rated as an eight on a scale of one to ten. The pain is associated with nausea and SOB. The pain was relieved when the patient took NTG tablet. Patient is negative for fevers, abdominal pain, and muscle joint pain. Patient has family history of CAD, and is a smoker. KNA.HPI elements_____________ ROS____________ PFSH____________ History level__________________2. 38-year-old new patient came in today with hip after falling off her deck this weekend. The pain comes and goes and she is using ice to keep the swelling down. Patient is negative for fever, SOB, CP, and gait problems. KNA, has HTN, DM.HPI elements_____________ ROS____________ PFSH____________ History level__________________3. Ms. Miller is here today to monitor his ongoing medical conditions. Patient has CAD, hyperlipidemia, and hypothyroidism. Patient has been complaint with her meds and getting exercise when she can. She is negative for SOB, GI, GU, muscle joint pain, chest pain, abd pain, GU and psych. See list for medication, patient is working as in a nursing home as an aid. Refill medsHPI elements_____________ ROS____________ PFSH____________ History level__________________4. Patient in today with bad sore throat has no fever. Did strep test, positive, Sent antibiotic to Walgreens follow-op PRN.HPI elements_____________ ROS____________ PFSH____________ History level__________________5. She is alert and oriented x3, pupils PERLA, TM’s are clear, cardio no murmur. How many organ systems_______6. ENT negative, GU negative, skin is warm to touch, patient has slight fever. How many organ systems________7. CV: RRR, GI: abdomen is non-tender, ENT: TM’s clear, Neck: no thyromegaly, Constitutional: BP 100/60 ______Fill in correct HPI Element1. It began in childhood__________________________2. The patient has been wheezing and coughing__________________________3. The indigestion happens mostly at night_____________________4. The pain takes my breath away. _______________________5. She tried elevating her head to take away the pain___________________Fill in ROS1. No weight changes__________________2. No hematuria_______________________3. No depression or suicidal thoughts.____________________True or False1. Medical necessity is the overarching criterion no matter how many HPI elements or ROS are documented. ____2. Chief complaint only has to be on the initial visit. _______3. Chronic can count as duration _____________4. Wheezing can be consider a location_____5. There are two types of exam 95 and the 97__________6. HEENT is an organ system_______7. You cannot give credit in the exam for pleasant ________8. You can mix and match the 95 and 97 exam on the same encounter._____ 1.Age is 19, weight 144, temp, 97.2, BP 108/64. TMS are negative. Throat is negative. Neck without adenopathy. Lungs are clear. She does significant tenderness in the paracervical musculature. a) How many organ system documented_______________ What 95 exam Level ____________________b) How many bullets _______________What 97 exam level_________________________ 2. Patient is well nourished in NAD. BP 129/78, pulse 96. Patient is A&O x3. Eyes: no conjunctival injection. Nose: turbinate’s erythematous 1+ boggy. Throat: OP erythematous. C/V: RR, no murmur. Lungs: +inspiratory wheeze RRL/RML improved after coughing. Skin: clear, no rashes. Extremities: no clubbing or cyanosisa) How many organ system_______________________ What 95 exam Level ____________________3. He is a clean, well/nourished, well-developed 15-year-old boy. He is alert and oriented to person, place and time. W:148, T: 99.2, BP: 100/54. ENT are all negative. Respirations are equal and unlabored, lungs are clear to auscultation. Hear is regular rate and rhythm, no murmurs, gallops or rubs. Abdomen has no tender areas. He has active bowel sounds. a) How many organ system documented______________________ What 95 exam Level _____________4. BP is 137/62, respiratory rate is 14, heart rate 75. The patient is alert and oriented x3, PERRLA, Neck is supple without lymphadenopathy, no thyroid enlargement or tenderness, lungs are decreased air entry, no rhonici or wheezes, Heart is normal S1 and S2 no murmurs, abdomen is soft no tenderness, extremities have +2 distal pulses. NO lower extremity edema or swelling, skin no rash, neurologic power 5/5 in all extremities. Sensation is intact and reflexes are +2. a) How many bullets identified on the 95 exam_____________ What 95 exam level___________5. General Appearance: well appearing, no acute distressEyes/Ears/Nose/Throat: pupils equal round and reactive to light. Canals clear and tympanic membrane visible. Respiratory: Lungs without crackles, rhonchi or wheezes. Cardiovascular: Hear has a normal RRRIntegumentary: Skin is without rashes, or suspicious nevi. Normal to palpationNeurological: Alert and oriented to person, place, time. Gait and station normal. a) How many organ system documented______________________ what 95 exam level______________b) How many bullets identified_______________________________ what 97 exam level _________6. HEENT: clearNeck: supple w/o bruitChest: lungs clearCV: RRRAbdomen: soft non-tenderGI: slightly more pronounced inguinal rig reducible w/o bowel sounds presenta) How many organ system documented________________________ what 95 exam level _____________b) How many bullets identified ___________________________ what 97 exam level __________________7. BP pressure is 157/85, respiratory rate is 20, heart rate is around 110. Alert and oriented x3. HEENT: Negative, Lungs: no wheezes. Abdomen: soft and lax. No tenderness. Extremities: +2 distal pulses. No lower edema and positive right big toe blackish.a) How many organ system documented______________________ what 95 exam level _____________8. HEENT: conjunctival prominence with erythema of bilateral upper and lower lids. EOM intact. Chin with ecchymosis.Neck: suppleLungs: clear to auscultation, assessment of respiratory effect negative, no wheezingHeart: RRR, no edema, clear to pedal pulsesAbdomen: normal bowel sounds and tenderness, normal liver and spleenSkin: no lesions a) How many organ system____________________________________ what 95 exam level____________9. General: Patient is awake, alert, communicative, and in no acute distressNeck: SuppleHEENT: ClearLungs: Clear to auscultation with decreased air entry in bases and has respiratory effort. Heart: S1, S2, Extremities: Edema present. a) How many organ system documented________________________ what 95 exam level______________10. Physical exam: pleasant female no istress her lungs are clear heart is regular abdomen is soft there is tenderness in the right upper quadrant there is no masses extremities are without cyanosis or clubbing. a) How many organ system documented.____________________________ what 95 exam level_________ Health Science Science Nursing HIT MISC Share QuestionEmailCopy link Comments (0)