2024 ED Core Post Test

1. A 77 yo former smoker-COPD patient presents to see you due to SOB and worsening cough with purulent sputum production of six days duration. Saturations on RA are 89% with ambulation, 93% at rest (96% baseline).  CBC, CMET are normal.  The CXR is negative (read and documented by you), but given the presentation, you recommend a short stay in the hospital to get “tuned up”.  He refuses, but agrees to follow-up with his PCP in the morning or call tonight if things worsen.  You agree with the plan and prescribe appropriate medications.  The total time for the encounter, including chart documentation, is 54 minutes.  You bill

2. A patient comes in with abdominal pain with dysuria, frequency, and slight nausea. She is 63, on a single antihypertensive medication, sees her PCP regularly.  She has a BMI of 28, is vegetarian, and a fitness instructor.  Temp is 99.0, BP 133/77, other vitals normal.  CBC shows a WBC count of 4,900 and her CMET is normal.  UA shows TNTC WBCs and bacteria.   The physician sees the patient after the NP (who documents the history and exam).  The physician reviews the history and exam and documents MDM for the encounter in total and bills a 99383.  Since both providers saw the patient, this is appropriate for a split/shared visit. Given this information who would this visit get billed under?

3. A 67-year-old with hypertension and diabetes presents with a mild frontal headache. She is on metformin and her sugars at home range fasting 70-110 and 100-125 pre-meal.  Blood pressures at home over the past week have ranged 145-156/88-95.  In the ED today, the pressure is 155/92 with a HR of 77 (reg).  She is on lisinopril 10mg only for blood pressure which she started 2 months ago.  CMET (glucose 110 non-fasting, eGFR 88) and CBC are normal.  You suggest she take two lisinopril (20mg) daily and you set her up for a follow-up visit within one week to the PCP with instructions to check her blood pressure closely and bring in numbers to the PCP for review.  You bill

4. CMS includes these conditions/procedures in their 30-day risk-standardized unplanned readmission measures to grade facilities, and if they have excess readmissions as compared to their peers, a reduction in payment can be applied. Which of the conditions below are NOT used in this calculation (select the condition that is NOT included)?

5. The Medicare Spend Per Beneficiary calculation performed by CMS (choose the ONE best answer)

6. The document that is best suited to streamline care transitions from the hospital stay is the discharge summary. Which of the following are noted as being important in capture of the discharge summary? (choose ALL that are correct)

7. Which of the following is a Major Comorbid Condition (MCC)?

8. If a patient has aspiration pneumonia, add which of the following to enhance the DRG? Choose ALL that are correct.

9. Choose the condition coded to the highest level of severity

10. You have a longstanding Medicare patient (not Medicare Advantage) come in with COPD exacerbation. He is not on oxygen at home, and his sats were 77% on RA and did not stabilize until he was placed on BiPAP.  But, this presentation is as before, and he usually stays 4-5 days before stabilizing enough to return home (and most of these hospitalizations requiring BiPAP). He refuses mechanical ventilation and has this noted on his chart.  You expect this admission to be as previous and to stay more than two midnights, so you ordered for inpatient care on admission.  The patient responded more quickly than expected and on the evening rounds of day two, asked to go home.  He is actually on room air, ambulates with stable vitals, and amazingly seems back to baseline.  His family came into town this morning and are here to visit him. They agree to watch over him and to get him in to his PCP tomorrow morning or call back tonight if he worsens.  Clinically, you agree with his request, and you feel good about the discharge plan. Because the patient did not pass two midnights, you should

11. A surgical procedure was admitted electively as “inpatient” for a procedure that is on the “Inpatient Only” list. After the procedure, the Attending Surgeon states she disagrees with that determination because the procedure was “not that hard” and the patient will be going home first of next morning, before the second midnight. You have knowledge of inpatient and observation status determination, so you offer to help her work through this process.  You recommend for her to

12. The CMS Medicare Advantage (MA) Final Rule in 2023 was released partly because

13. Which of the following, if documented correctly, could aid in capturing an inpatient status for the heart failure patient on day ONE? Select all that apply.

14. The session mentioned the use of the HEART and EDACS scores as tools for ED evaluation of chest pain. The HEART score of a patient is 3 and the EDACS is 11.  This would indicate possible 

15. True statements about atrial fibrillation (select all that are TRUE)

16. Which of the following would NOT support continued hospital stay? (Select ALL that apply)

17. CMS includes these conditions in their 30-day risk-standardized unplanned readmission measures to grade facilities. If excess readmissions are realized as compared to their peers, a reduction in payment can be applied.  Which of the conditions below are used in this calculation (select all that are included)?

18. Regarding screening tools for pneumonia, the following is true (select all that are correct):

19. The National Institutes of Health Stroke Scale (NIHSS) is one tool to use to help determine whether a patient deems to meet medical necessity for inpatient level of care.  Which score below is indicative of such consideration from the 15 elements in the tool? (choose the most correct answer)

20. A 67-year-old hypertensive patient notes RUE clumsiness at his evening meal (8pm).  He presents to the ED where a CT is completed showing no acute CVA.  He is placed in-house for OBSERVATION status. The next morning the speech issues have resolved.  The neurological evaluation occurred at 0700 AM, 11 hours after symptom onset.  No thrombolytics were used.  He is discharged but did complete an MRI that was already scheduled before leaving (but after discharge) It shows a small ischemic infarct that appears new in the basis pontis.  The most appropriate diagnosis for this hospital stay is

21. A 67-year-old hypertensive patient notes RUE clumsiness at his evening meal (8pm).  He presents to the ED where a CT is completed showing no acute CVA.  He is placed in-house for OBSERVATION status. The next morning the speech issues have resolved.  The neurological evaluation occurred at 0700 AM, 11 hours after symptom onset.  No thrombolytics were used.  He idid complete an MRI that was already scheduled before leaving that showed a small ischemic infarct that appears new in the basis pontis.  The most appropriate status for this hospital stay is

22. A condition is noted to be an infection-related condition that is causing organ disfunction that is manifesting as hypotension unresolved by fluid resuscitation requiring vasopressors. The lactate level is >2mmol/L after adequate IVF boluses.  This clinical state is best defined as

23. An 81-year-old female from a local nursing home is being considered for hospitalization due t a UTI. What would lean you towards an inpatient vs observation status determination?  Choose ALL that are appropriate.

24. The following D-Day (day two) findings would merit an observation patient being placed as inpatient EXCEPT