Communication and Documentation Flashcards

Which CPT modifier indicates a procedure was performed bilaterally, such as bilateral myringotomy with tubes?

Answer: -50

Modifier -50 denotes a bilateral procedure performed during the same session.

An ENT evaluates a new problem and performs a same-day laryngoscopy. Which modifier on the E/M service indicates a significant, separately identifiable evaluation?

Answer: -25

Modifier -25 is appended to an E/M service that is significant and separately identifiable from a same-day procedure.

A patient leaves the hospital against medical advice after a peritonsillar abscess drainage. What should the documentation include?

Answer: Patient capacity, risks explained, alternatives offered, and follow-up instructions

AMA documentation should capture capacity, risk discussion, alternatives, and follow-up arrangements.

Which statement best describes shared decision-making for a patient choosing between watchful waiting and tubes for recurrent otitis media?

Answer: The clinician presents evidence and options, and the family's values guide a joint decision

Shared decision-making combines clinical evidence with patient or family preferences to reach a joint decision.

A clinician discovers an error in a prior signed EHR progress note. The correct method of correction is to:

Answer: Add an addendum identifying the correction, with date, time, and signature

EHR corrections are made by dated, signed addenda that preserve the original entry.

When documenting flexible laryngoscopy findings of vocal fold paralysis, which detail is most important to record?

Answer: Side affected, position of the paralyzed fold, and glottic closure

Laterality, fold position, and glottic competence guide management and must be documented.

A deaf patient whose primary language is American Sign Language requests an interpreter. Under the ADA, the practice should:

Answer: Provide a qualified ASL interpreter at no cost to the patient

The ADA requires effective communication, including qualified interpreters at no charge to the patient when needed.