Certified Cardiovascular and Thoracic Surgery Coder (CCVTC) Practice Exam

These questions are part of the practice quiz. Start practicing

• What documentation is mandatory for all medical encounters according to standard practices?
• What does a 'Comprehensive' level exam require in terms of documentation?
• Which of the following best describes "modifying factors" in HPI?
• How many bullets must be documented using the general multisystem 1997 exam template?
• Should coders train physicians to document based on achieving higher levels with minimal additions?
• What is the value associated with a 'Moderate' amount of data classification?
• Which factors must be documented when selecting an Evaluation and Management (E/M) level based on time?
• What must be demonstrated to validate critical care service billing?
• Which system is characterized by symptoms such as itching, rash, and changes in scars or moles?
• What is considered the best guide regarding the Medical Decision Making (MDM) component of the guidelines?
• How can the patient's past history contribute to their current medical assessment?
• According to the 1997 Documentation Guidelines, how many bullets are required for an Expanded Problem Focused Exam?
• If a physician is billed separately for reading a test, can they be credited for interpreting and visualization of the test?
• Can residency programs qualify for billing primary care office visits?
• Which review of systems includes symptoms like painful urination and flank pain?
• In an E/M encounter, when must counseling or coordination of care account for more than 50% of the total time?
• What is the correct definition of a Comprehensive single system exam?
• What service is used while the physician evaluates a patient's condition to see if it resolves or worsens?
• Fatigue and exercise intolerance fall under which category of review of systems?
• Is the concept of incident-to recognized in a facility setting?
• What does the term "workup" refer to in a clinical context?
• Which statement about coding for different levels of service is correct?
• What is a critical condition in medical coding?
• What is a primary concern regarding the 1997 Documentation Guidelines (DGs)?
• Which of the following is NOT a body area for the exam?
• Which review of systems (ROS) includes symptoms such as sensitivity to noise and ear pain?
• How many elements are required in an extended HPI?
• In terms of minor problems that may determine medical assistance, how much is each worth?
• Which HPI element is represented by symptoms such as ear pain or RUQ pain?
• How many points is assigned for a new problem to the patient with no additional workup needed?
• What modifier is utilized for a teaching physician when a resident is involved in patient care?
• Who is responsible for billing if a patient is seen in the hospital by a Non-Physician Provider (NPP) and the physician reviews the chart?
• Which element of History of Present Illness (HPI) describes circumstances surrounding an event?
• Which of the following is an example of a modifying factor?
• Can a service be billed if it is not clear that the physician performed a face-to-face encounter with the patient?
• What are the types of Non-Physician Practitioners (NPP)?
• Who is authorized to use initial observation codes?
• Can the 1995 and 1997 documentation guidelines be used simultaneously?
• Which element in HPI is concerned with the severity of a condition?
• How many body areas or organ systems are included in a Problem focused exam according to the 1995 DGs?
• Which review of systems addresses visual disturbances and eye pain?
• What does the urgency of the visit refer to in the context of risk indicators?
• What does the term 'critical' typically signify in a clinical setting?
• Is scheduling routine blood work to monitor medication side effects considered to be additional workup in MDM?
• What is a significant downfall of the 1995 Documentation Guidelines?
• Are coders able to make decisions about medical necessity independently?
• What does the term 'Family Hx' refer to in medical documentation?
• How much is the physician reimbursed if incident-to requirements are met?
• Sore throat and mouth lesions are part of which review of systems?
• What does the "timing" element in HPI describe?
• What is the point value assigned to a new problem requiring additional workup?
• What does the HPI element refer to in medical documentation?
• What symptoms are common in the gastrointestinal ROS?
• What is the primary reason the level of medical necessity and work of the provider is not penalized?
• What are the levels of risk associated with medical coding?
• What is required to fulfill the criteria for "complete" ROS?
• Which HPI element refers to the position or site of the chief complaint?
• What are indicators of risk in a medical evaluation?
• According to the 1997 Guidelines, how many bullets must be documented for a Comprehensive Exam?
• What symptoms are included in the cardiovascular ROS?
• According to the 1995 Documentation Guidelines, which of the following is NOT an organ system evaluated during exams?
• Are initial IP codes submitted solely by the admitting provider?
• When an ER physician refers a patient to another physician, how should visits be reported?
• How many points are established for worsening conditions according to the exam guidelines?
• In the HPI, what is considered an important factor to determine the severity of the patient's condition?
• According to the 1995 Documentation Guidelines, how many organ systems must be included for a Comprehensive exam?
• What type of HPI element describes an event that occurred in childhood, two weeks ago, or for several years?
• Which of the following is a General Principle of Documentation?
• What does the HPI element "Timing" refer to?
• Which body area is assessed in connection with symptoms such as cough or difficulty breathing?
• How many HPI elements are typically found in a Brief HPI?
• How are critical care services reported?
• Which of these elements is NOT part of assessing the complexity of medical decision-making?
• How is risk determined in a clinical context?
• Which body system includes areas such as the gastrointestinal and respiratory systems?
• How should the first day of an observation patient admission be coded?
• What system is characterized by changes in blood sugar levels and sudden changes in weight?
• Must a consulting physician provide a written report to the requesting physician regarding services performed?
• What is the coding scheme when an ER physician refers a patient to another doctor upon admission?
• Is a statement that the remaining systems are reviewed and noted as "Negative" sufficient for a complete Review of Systems (ROS)?
• For both 1995 and 1997 Documentation Guidelines, must a physician elaborate on abnormal findings?
• Which area would be examined for signs of swelling or abnormal tenderness?
• Which type of HPI element describes the intensity of pain on a scale of 1-10?
• What is the primary focus when a physician participates in patient management?
• What term describes a patient's statements regarding the severity of their condition?
• What type of pain is described by the HPI element "throbbing pain"?
• Which body system includes the cardiovascular and neurological components in a general multisystem exam?
• What does the term 'Context' refer to in HPI elements?
• When coding with teaching physicians and residents, how is the note utilized?
• What should a provider indicate if patient history cannot be obtained?
• What are the four levels of the 1995 examination?
• What are the two criteria that must be met to bill for incident-to services performed by a Non-Physician Provider (NPP)?
• What role does a physician play in determining the necessity of a service?
• In which situation may the modification of a symptom be noted in HPI?
• Does AAPC expect examinees to select the E/M code based on medical necessity?
• What are the levels of diagnosis and treatment options and how many points is each worth?
• Which of the following is NOT included in the ROS systems?
• How many systems are covered in an Extended Review of Systems (ROS)?
• What type of HPI (History of Present Illness) element is represented by symptoms such as sore throat and runny nose?
• What is the highest point value in the data classification system?
• What is the purpose of the organ system categories in examination?
• How many points are established for stable or improved conditions?
• If a provider fails to document a minimum of a detailed history and examination for the initial inpatient encounter, what occurs?
• What is one of the purposes of documenting a patient's visit?
• What aspects contribute to points for the amount and complexity of data?
• What is primarily evaluated during a Review of Systems (ROS)?
• How should ROS and PFSH be updated from an earlier encounter?
• How many history items are required for a complete Past Family Social History (PFSH) in established outpatient settings?
• What differentiates an expanded problem focused exam from a detailed exam according to 1995 documentation guidelines?
• Can a physician bill incident-to services if the NPP sees the patient for a new problem?
• What documentation is crucial for establishing medical necessity in patient visits?
• In the context of Documentation Guidelines, which aspect is emphasized for less subjectivity?
• Which body area includes the chest along with the breast and axilla?
• How is time defined in an office and outpatient setting?
• What does 'Associated Signs and Symptoms' refer to in medical evaluation?
• Which element indicates the time frame of when a complaint first occurred?
• Which of the following describes types of Past Family and Social History (PFSH) levels?
• What is evaluated during the Review of Systems in a patient assessment?
• Which of the following HPI elements indicates the timing of an event?
• What is required for a detailed examination according to the 1995 Documentation Guidelines?
• What system may involve allergies to medications and environmental substances?
• When is it essential for a physician to include all relevant history for coding?
• What system includes symptoms like dizziness, seizures, and memory loss?
• Which system is indicated by symptoms such as unusual bleeding and swollen glands?
• Do the 1995 and 1997 Documentation Guidelines recognize the same number of body areas?
• Symptoms such as restlessness and irritability may point towards what type of issues?
• According to the 1995 guidelines, how many body areas and/or organ systems constitute a detailed exam?
• What does "Social History" describe in patient documentation?
• What does HPI stand for in a medical setting?
• In which situation should assumptions based on age be avoided?
• What should a provider document if reviewing external records during a patient encounter?
• What is one key aspect of an extended HPI according to the revised E/M DGs?
• What is the highest level that can be billed by a resident without the presence of a teaching physician?
• If a patient reports a sore throat and denies specific symptoms, is there a distinct component of both HPI and a separate ENT system review?
• Which component is essential for a comprehensive patient examination according to 1995 DGs?
• What encompasses a patient’s experiences with diseases, operations, injuries, treatments, and medications?
• Do both the 1995 and 1997 guidelines have the same number of levels of exam?
• What is the range of body areas and/or organ systems for an Expanded Problem Focused exam according to the 1995 DGs?
• What does "Duration" refer to in HPI documentation?
• How many bullet points must be documented for a 1997 Detailed exam?
• Which area is not a subjective area of the 1995 Documentation Guidelines (DGs)?
• Which element of the medical history includes information gathered from patients and non-patients?
• Which requirement must be met when services provided by teaching physicians are billed to Medicare?
• What is the primary reason for requiring specific documentation elements in medical coding?
• In a Problem pertinent Review of Systems (ROS), how many systems are involved?
• Which term describes the chronological description of the development of a patient's present illness?
• Which of the following is not an Element of HPI?
• Symptoms like joint deformities and noise with joint movement are included in which ROS?
• Which of the following factors is worth 2 points for the amount and complexity of data during coding?
• Which of the following is NOT a component of the HPI?
• How many points are awarded for discussing results with a performing or consulting physician?
• What does the term "Associated S and Sx" refer to in a patient's history?
• According to the 1995 guidelines, what is required for an Expanded Problem Focused exam?
• Which of the following is NOT a level of History (Hx)?
• What is the primary focus of the Chief Complaint in a patient's history?
• What is the role of the supervising physician when billing for incident-to services?
• How many history items are necessary for a complete PFSH in new outpatient settings?
• What is typically included in the Family Hx review?
• During which scenario is a resident allowed to code services provided without supervision?
• Which modifier is applied when a resident provides a service without the presence of a teaching physician?
• How is the coding complexity assessed concerning the patient's medical history?
• For which of the following would 'Location' be an HPI element?
• What kind of documentation is necessary for coding an initial inpatient encounter?
• Which system is associated with symptoms of depression, anxiety, and suicidal thoughts?
• How many systems must be reviewed in a Complete ROS?
• Which of the following best describes the quality aspect of HPI?
• What value is assigned to 'Limited' amount of data?
• In a Pertinent PFSH, how many histories must be documented?
• Symptoms including light sensitivity and floaters are primarily analyzed under which ROS?
• What are the types of Review of Systems (ROS)?
• Should an assumption be made based on a patient's age if Medicare is not mentioned?
• What does the 'GC' modifier signify in medical billing?
• Which of the following describes a quality element in HPI?
• Which component is considered the least subjective aspect of the Documentation Guidelines (DGs)?
• What modifier is used for initial IP codes designated by the admitting physician?
• Which symptoms are associated with the respiratory ROS?
• When a patient's condition worsens and necessitates admission, how should it be coded?
• In an inpatient setting, how is time defined?
• Which HPI element is defined as the patient’s statements about what makes the problem better or worse?
• Which review of systems would evaluate symptoms like swelling around eyes and tearing?
• Which term best describes the Nature of Present Illness (NPI)?
• Which review of systems is concerned with symptoms such as frequent sneezing and postnasal drip?