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A patient has the following history: breast CA s/p chemoradiation therapy and mastectomy.
Based on this, does the patient meet level 5 billing criteria for this scenario of the chart? -
Answer -Yes, the PHx meets level 5 billing criteria
A 45 year old male presents to the ED with a constant ripping, tearing pain to his central chest
radiating strait to his back with associated nausea that began 1 hour ago. What element in
constant? - Answer -timing
Read through the PE and decide if this meets the Level 5 billing criteria:
Genera/Constitutional: NC, AT
Eyes: PERRL, EOMI
ENT: moist oral mucosa
Cardiac: irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no gallops
Respiratory: Lungs clear, no respiratory distress, no wheezing, no rales, no rhonchi
Neurological: A&O x 4
Psychiatric: normal affect - Answer -No, the PE does not meet level 5 billing criteria
Fill in the blank: Critical care must be at least a minimum of _______. - Answer -30 minutes
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,Among the following diseases listed, select the ones that qualify for CCT.
Acute MI
Stable angina
Sepsis
PE
Pleuritis
DKA
CVA
PTX
Costochondritis
A-fib with RVR
ACS - Answer -Acute MI
Sepsis
PE
DKA
CVA (hemorrhagic or ischemic)
PTX
A-fib with RVR
ACS (acute coronary syndrome)
Match each critical care dx with it's associated procedure
PTX
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, Sepsis
Cardiac Arrest
Respiratory Failure
Acute Exacerbation CHF / COPD (severe)
Abnormal Heart Rhythm - Answer -PTX: chest tube
Sepsis: central line placement
Cardiac arrest: CPR
Respiratory failure: Intubation
Acute exacerbation CHF/ COPD (severe): CPAP/ BiPAP
Abnormal heart rhythm: cardioversion
Which of these procedures qualify as critical care procedures and would indicate that critical
care time must be documented on a patient?
Cardioversion
CPR
LP
Central line placement
Chest tube
CPAP/BiPAP
Intubation
Sedation
Arthrocentesis - Answer -Cardioversion
CPR
Central Line Placement
Chest Tube
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