Medical Billing & Coding - Certification Tests (Actual 2025/2026)
66 Questions And Answers Updated
What symptoms are included in ROS (Review of Systems) for
Constitutional Classification
- Usual weight.
- recent weight changes,
- fever,
- weakness,
- fatigue
What items are included in the category of Family History
Significant information about:
- the health status or cause of death of parents, siblings, and children
- Specific diseases related to problems identified in the CC, HPI, or ROS
What items are included in the category of Social History
An age-appropriate review of past and current activities that include
significant information about:
- Marital status and/or living arrangements
- Current employment
- Occupational history
-Use of drugs, alcohol, and tobacco
- Level of education
- Sexual history
,- Other relevant social history
How many elements of a history are always included in varying degrees
in all patient encounters
Three (3);
- HPI
- ROS
- PFSH
How is the degree, level of HPI, ROS, and PFSH determined
They are determined by the CC (Chief complaint) or presenting problem
of the patient during the current encounter that is being documented.
How many history levels are there, and what are they?
There are four levels
- Problem focused
- Expanded problem focused
- Detailed
- Comprehensive
What are the History levels based on to determine the level?
History levels are based on the extent of the history taken and the
answered received during that process of the examination. They must
, be documented in the Medical Records in order to be referenced in the
choice of History level.
What are the items included in a Problem Focused History level?
The Dr. focuses on the CC and a brief history of the present problem of
a patient. A brief history includes"
- A review of the history regarding pertinent information about the
present problem or CC.
- It centers around the severity, duration, and symptoms of the CC.
- Does not have to include PFSH or ROS.
What are the items included in a Expanded Problem Focused History
level?
The Dr. focuses on the CC, obtains a brief history of the present
provblem, also performs a problem-pertinent review of systems.
This hx includes:
- a review of the Organ System (OS) most closely related to the CC
- It requires 1 - 3 HPI elements, 1 OS mostly related to the CC, no PSFH
What are the items included in a Detailed focused History level?
The Dr. focuses on a CC and obtains an extended history of the present
problem, and extended ROS, and a pertinent PFSH directly related to
the patient's problem.
- The extended ROS includes a review of the system directly related to
the CC
- Plus additional related systems
66 Questions And Answers Updated
What symptoms are included in ROS (Review of Systems) for
Constitutional Classification
- Usual weight.
- recent weight changes,
- fever,
- weakness,
- fatigue
What items are included in the category of Family History
Significant information about:
- the health status or cause of death of parents, siblings, and children
- Specific diseases related to problems identified in the CC, HPI, or ROS
What items are included in the category of Social History
An age-appropriate review of past and current activities that include
significant information about:
- Marital status and/or living arrangements
- Current employment
- Occupational history
-Use of drugs, alcohol, and tobacco
- Level of education
- Sexual history
,- Other relevant social history
How many elements of a history are always included in varying degrees
in all patient encounters
Three (3);
- HPI
- ROS
- PFSH
How is the degree, level of HPI, ROS, and PFSH determined
They are determined by the CC (Chief complaint) or presenting problem
of the patient during the current encounter that is being documented.
How many history levels are there, and what are they?
There are four levels
- Problem focused
- Expanded problem focused
- Detailed
- Comprehensive
What are the History levels based on to determine the level?
History levels are based on the extent of the history taken and the
answered received during that process of the examination. They must
, be documented in the Medical Records in order to be referenced in the
choice of History level.
What are the items included in a Problem Focused History level?
The Dr. focuses on the CC and a brief history of the present problem of
a patient. A brief history includes"
- A review of the history regarding pertinent information about the
present problem or CC.
- It centers around the severity, duration, and symptoms of the CC.
- Does not have to include PFSH or ROS.
What are the items included in a Expanded Problem Focused History
level?
The Dr. focuses on the CC, obtains a brief history of the present
provblem, also performs a problem-pertinent review of systems.
This hx includes:
- a review of the Organ System (OS) most closely related to the CC
- It requires 1 - 3 HPI elements, 1 OS mostly related to the CC, no PSFH
What are the items included in a Detailed focused History level?
The Dr. focuses on a CC and obtains an extended history of the present
problem, and extended ROS, and a pertinent PFSH directly related to
the patient's problem.
- The extended ROS includes a review of the system directly related to
the CC
- Plus additional related systems
