Answer the following statements true (T) or false (F)
1. In general, medical decision making with respect to a diagnosed problem is harder than that for an identified but undiagnosed problem.
2. For a presenting problem without an established diagnosis, the clinical impression may be stated as a "possible" or "rule-out" diagnosis.
3. If a physician considers findings from discussions with family members in his or her medical decision making, documentation in the chart can simply state "additional history obtained from family" without providing additional detail.
4. Time is considered the controlling factor for determining the level of E/M service if counseling with the patient or family members constitutes more than 50% of the encounter.
5. Audits performed on a regular basis will confirm that documentation and coding were appropriate for the level of service provided or will identify problems.
1. FALSE
2. TRUE
3. FALSE
4. TRUE
5. TRUE
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