D. Only a Level 3 code requires a comprehensive ROS C. Both codes require high complexity decision...

D. Only a Level 3 code requires a comprehensive ROS

C. Both codes require high complexity decision making

B. Level 2 codes require examination of only 2 body areas

A. Both codes require a comprehensive history and physical

Which statement is true regarding level 2 and level 3 initial inpatient codes?

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Both level 2 and level 3 initial inpatient codes require a comprehensive history and physical. The difference is in the medical decision making; complexity is moderate for level 2 and high for level 3.

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D. Medical decision making

C. Review of systems

B. Past medical history

A. Interval history

All are assessed in key component documentation of subsequent inpatient visits EXCEPT


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For subsequent inpatient visits, history and physical exam documentation expectations are reduced, with preservation of medical decision making criteria. No new Past/Social/Family history is required for subsequent inpatient visits. Some ROS data is required to support a higher history level. However, just as for outpatients, subsequent care visits are coded based on 2 of the 3 key components.


D. Medical decision making risk

C. Time spent by the physician on the unit

B. Age of the patient

A. Duration of hospitalization

How are discharge service codes selected?


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Discharge codes are based on time spent on the unit discharging the patient.


D. Observation code only

C. Observation Admission code + Observation Discharge code

B. Observation code + Observation Discharge code

A. Observation code + Standard Discharge code

A patient is “admitted for observation” at 5 AM and discharged at 2 PM. You should bill:


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Standard observation codes include bundled payment for same day discharge. A separate

Observation Admission code and Observation Discharge code are used only when services spread

over 2 calendar days.

D. There is only one Observation Discharge code

C. Age of the patient

B. Medical decision making risk level

A. Time spent by the physician on the care unit discharging the patient

How is an Observation Discharge code selected?


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There is only one Observation Discharge code, used for next calendar day discharge of an observation

patient. Unlike inpatient discharge, there is no time based assessment.

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D. Only a Level 3 code requires a comprehensive ROS C. Both codes require high complexity decision...

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