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71 Cards in this Set
- Front
- Back
What 3 components are involved in Evaluation and Management services?
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1) History
2) Examination 3) Clinical Decision-making |
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What is the time frame in which a patient is considered an existing or established patient?
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Three years
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What are some reasons why an existing or established patient can receive E/M services?
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1) Periodic Evaluations
2) Exacerbation of an existing Complaints 3) New chief complaint 4) Release or discharge from condition-based care |
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What should a history lead a chiropractor to conclude?
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1) Differential diagnosis possibilities
2) Necessary examination components 3) Red flags indicating patient referral |
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What 3 things is a patient history comprised of?
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1) HPI -History of present illness
2) ROS - Review of systems 3) PFSH - Past family and social health |
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What is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient might be experiencing?
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ROS - Review of systems
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What are the 3 types of ROS?
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1) Problem pertinent
2) Extended 3) Complete |
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What are the questions that should be asked when a patient acknowledges a concern during the ROS?
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1) How long have you had the problem? (onset)
2) Who are you seeing for it? (healthcare provider) 3) What is being done for it? (Method of treatment) 4) How is it currently? (Status of the issue) |
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What information is incorporated in a Past History review?
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Past illnesses, surgeries, injuries, and treatments including medication
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What information is incorporated in a Social History review?
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Smoking, alcohol, other tobacco use, exercise, diet, and sexual habits
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What information is incorporated in a Family History review?
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Age appropriate past and current diseases among family members
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When do you discuss time frame, fee for the exam, and answer any additional questions that the patient has?
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Before the exam
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What does a Problem focused exam include?
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1-5 elements total that encompasses 1 or more systems.
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What does an expanded problem focused exam include?
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6 elements total that encompasses 1 or more systems.
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What does a Detailed exam include?
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6 Systems and encompasses 2 elements in each system
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What does a Comprehensive exam include?
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9 systems that encompasses all the elements in each of the systems.
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What does forming the diagnosis require?
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Identifying the deficiencies from the exam and matching them to the most appropriate diagnosis.
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What are the 4 parts that we use to organize a diagnosis?
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1) Source
2) Cause 3) Associated 4) Resulting |
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In organizing a diagnosis, what is "the condition emitting the symptoms" used to describe?
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Source
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In organizing a diagnosis, what is "the reason for the patients condition" used to describe?
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Cause
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In organizing a diagnosis, what is "Regional functional deficit" used to describe?
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Associated
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In organizing a diagnosis, what is "Deficiency in activities of daily living" used to describe?
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Resulting
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In organizing a diagnosis, what can be matched with a chiropractic adjustment?
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Cause
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In organizing a diagnosis, what can be matched with a therapeutic exercise?
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Associated
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In organizing a diagnosis, what can be matched with a therapeutic activity?
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Resulting
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What material can be linked directly to a patient initiative?
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Chief Complaint
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Recording what enables the ability to separate multiple occurrences of similar chief complaints into distinct treatment cases?
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Date of Onset
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(T/F) One procedure can be matched to multiple diagnoses?
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True
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(T/F) One diagnosis can be matched to multiple procedures?
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False
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What are some elective services that should not be billed to third party payers?
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1) Nutritional Supplements
2) Low level laser 3) Decompression Therapy 4) Kinesio Taping 5) Protocols that diagnose subluxation in lieu of an exam 6) Protocols that improve STATIC postural correction |
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What is the way that patient improvement is measured?
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Goals
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What is the simple process of turning an exam or history finding into a positive achievement?
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Creating a Goal
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What are adjusting goals related to?
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Improving segmental function
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What are short term goals used to decrease pain and improve the ability to sit, stand, and walk so functional-oriented care may begin?
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Passive Goals
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What are derived from regional functional deficiency from spasm, weakness, and loss of motor control and improve strength, balance, ROM, and dynamic postural stabilization?
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Functional Goals
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What are specific to certain activities such as lifting, mobility, self-care, work-related activities, driving, and using equipment?
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Activities of Daily Living Goals
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What does HMP stand for?
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Health Maintenance Promotion
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What documents the anticipated outcome of the patients care?
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Prognosis
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What are the 2 prognosis choices for patients with complaints and functional deficiencies?
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1) Condition expected to fully resolve
2) Condition not expected to fully resolve but continued therapy expected to result in functional improvement. |
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What are conditions that require alteration or specific action to the way care is routinely provided?
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Red Flags
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What is an example of an Absolute red flag?
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Chiropractic adjustment is contraindicated.
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What is an example of an Relative red flag?
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Patient requires more specialized attention when chiropractic adjusting is utilized.
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What Does 99201 mean?
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Focused History
Focused Examination Straightforward Clinical decision making |
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What does 99202 mean?
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Low to Moderate Presenting Problem
Expanded History Expanded Examination Straightforward Clinical decision makeing |
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What does 99203 mean?
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Moderate Presenting Problem
Detailed History Detailed Examination Low Clinical Decision Making |
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What does 99204 mean?
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Moderate to High Presenting Problem
Comprehensive History Comprehensive Examination Moderate Clinical Decision Making |
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What does 99205 mean?
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High Presenting Problem
Comprehensive History Comprehensive Examination High Clinical Decision Making |
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What new patient examination code do chiropractors use most often?
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99202
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What 2 new patient examination codes should not be used by chiropractors and are considered red flags to a third party payer?
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99204, 99205
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For a new patient examination, how many boxes must be met or exceeded to qualify for a particular code?
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3 boxes
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For an existing patient examination, how many boxes must be met or exceeded to qualify for a particular code?
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2 boxes
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What is the most common existing patient evaluation and management code to measure progress used by chiropractors?
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99212
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What is the most common existing patient evaluation and management code for a new complaint used by chiropractors?
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99213
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What is a nodule in skeletal muscle that causes a REFFERED pain pattern when palpated?
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Active Trigger point
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What is a nodule in skeletal muscle that causes a LOCALIZED pain pattern when palpated?
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Latent Trigger point
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What two portions of P.A.R.T must always be positive in order to perform a spinal adjustment?
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A or R
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What is the code for a spinal adjustment in 1-2 regions?
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98940
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What is the code for a spinal adjustment in 3-4 regions?
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98941
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What is the code for a spinal adjustment in 5 regions?
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98942
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When would you use codes for Hot/Cold packs?
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When exam documents inflammation, muscle spasm, or myalgia
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What is the code for hot or cold pack application?
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97010
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What is the code for a hot or cold pack bundled as a component of therapeutic exercise?
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97110
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What is the minimum amount of time that you can bill a full cycle?
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8 minutes
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What is the minimum amount of time you can bill two full cycles?
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23 minutes
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What is the time increment for 1 cycle of therapeutic exercise or activity?
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15 mins
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What is the code for Therapeutic exercise, direct patient contact?
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97110
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What is the code for Therapeutic exercise, one provider to a group of patients?
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97150
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What is the code for a non-covered (elective) Therapeutic exercise, direct patient contact?
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BCAAI
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What is Therapeutic Activities used for?
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Exercises that restore specific activities to ADL
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What is the code for Therapeutic activity, direct patient contact?
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97530
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What is the code for Neuromuscular re-education, direct patient contact?
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97112
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