Office Visit (E&m) Coding

The correct answer is C. Coding for established patients requires that 2 of 3 key components are met. This means that when coding for an established patient, the healthcare provider must document at least two out of the three key components: history, examination, and medical decision making. This is different from coding for a new patient, where all three key components must be documented.

The correct answer is C. Evaluation and Management, used as the official coding definition for an office visit. This is because E&M refers to the process of evaluating a patient's condition and managing their care, which is typically done during an office visit. It is used as a coding definition to classify and bill for these types of visits.

If more than 50% of the patient encounter was spent on counseling, it would be appropriate to choose time-based coding. This is because time-based coding allows for billing based on the amount of time spent with the patient, rather than the complexity or nature of the service provided. In this case, since counseling took up the majority of the visit, it would be more accurate to use time-based coding to reflect the time spent on counseling.

The codes A, F, and G are considered "Key Component" codes for "new" patients because they are essential components in evaluating and treating a new patient. Patient history (A) provides important information about the patient's medical background and helps in understanding their current health status. The exam (F) involves a physical examination of the patient, which is crucial in diagnosing and treating their condition. Medical decision making (G) involves the physician's assessment and analysis of the patient's condition, which guides the treatment plan. These three components are necessary for providing comprehensive care to new patients.

The correct answer is B. CPT or HCPC code. In a patient's medical chart or superbill, CPT (Current Procedural Terminology) or HCPC (Healthcare Common Procedure Coding System) codes are used to describe the specific medical procedures or services provided to the patient. These codes provide a standardized way of communicating to the payer the reason for the patient's medical care and help in the billing and reimbursement process. The codes provide detailed information about the specific services rendered, allowing the payer to understand the medical necessity of the care provided.

The "nurse-only" code is permitted to be used when certain brief services, such as counseling and education, are delivered by ancillary staff. This means that these services can be provided by individuals other than registered nurses, such as licensed vocational nurses (LVN) or public health nurses (PHN), as long as they are considered ancillary staff. This code does not apply specifically to services delivered only by registered nurses (RN), as stated in option A. Option B includes a broader range of healthcare professionals, not just ancillary staff. The correct answer is option C.

The correct answer is A. ICD-9 code. In a patient's medical chart or superbill, the ICD-9 code is used to explain "what" happened at the medical encounter. The ICD-9 code is a diagnostic code that represents the patient's condition or illness. It is used for billing purposes and provides a standardized way to communicate the patient's diagnosis to the payer. The ICD-9 code helps the payer understand the reason for the medical encounter and determine the appropriate reimbursement or coverage.