Ch. 19 Evaluation and Management Flashcards
What category of codes should be used to report an evaluation and management service provided to a patient in a psychiatric residential treatment center?
d. Nursing facility services
Response Feedback:
Rationale: The guidelines for Nursing Facility Services state, “These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center.”
If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)?
c.
Quality
Response Feedback:
Rationale: Quality describes a problem’s characteristics. Sharp, stabbing or dull refer to the characteristics of pain.
Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days.
c.
Location, quality and duration
Response Feedback:
Rationale: Location (headache), quality (blurry), duration (past three days).
A provider makes a home care visit to a 63 year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home bound for the last year. The last visit from this provider was four months ago to manage his DM. The physician performs an expanded problem focused examination and low MDM. The provider speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported?
d.
99348
Response Feedback:
Rationale: According to CPT® E/M guidelines, Home Services codes (99341-99353) are used to report evaluation and management services provided in a private residence. This is an established patient to the provider. Established patient home care codes require two of three key components. The provider performed an expanded problem focused exam and low MDM resulting is code 99348.
A 25 year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED provider is unable to get a history due to patient’s altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED provider documents total critical care time 25 minutes. What CPT® code is reported?
c.
99285
Response Feedback:
Rationale: According to CPT® Critical Care Services guidelines: “99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date is reported with the appropriate E/M code.” For this encounter the provider is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index look for Evaluation and Management/Emergency Department. You are referred to 99281-99285. For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient’s condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is high. The proper code is 99285. There is also a statement in the description of 99285 that states, “within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status.”
A 32 year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?
a.
99242
Response Feedback:
Rationale: The three Rs of consultation are documented (request, render, reply). The consultation code range is 99241-99245 and applies to new or established patients. Consultations require three key components. The documentation states the history and exam were expanded problem focused and the MDM is straightforward. These three key elements meet the requirement for 99242.
A pediatrician is asked to be in the room during the delivery of a baby at risk for complications. The pediatrician is in the room for 45 minutes. The baby is born and is completely healthy, not requiring the services of the pediatrician. What CPT® code(s) is/are reported by the pediatrician?
a.
99360
Response Feedback:
Rationale: The physician provider standby services. In the CPT® Index look for Standby Services and you are directed to 99360. 99360 is reported based on time. Each 30 minutes is reported if only the entire 30 minutes is met. 99360 with 1 unit is the correct code choice.
The attending provider at the hospital spent 25 minutes with the patient in the morning and another 15 in the afternoon examining the patient, writing discharge orders and giving discharge instructions to the patient. What CPT® code is reported for the discharge?
d.
99239
Response Feedback:
Rationale: In the CPT® Index look for Hospital Services/Inpatient Services/Discharge Services and you are directed to code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. They may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time. All of the time spent by the discharge provider on the discharge date is included in the time. The provider spent a total of 40 minutes with the patient on the discharge date. 99239 is the correct code choice.
The EMS brought a 31 year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported?
d.
99285
Response Feedback:
Rationale: In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.
After moving across country, Ms. Robbins took her 2 year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age/gender appropriate history, exam, and provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported?
c.
99382
Response Feedback:
Rationale: This is a new patient to the pediatric clinic. Look in the CPT® Index for Preventive Medicine/New Patient and you are directed to code range 99381-99387. The code selection is based on age. Code 99382 is for ages 1-4 making it the correct code choice.
Dr. Howitzer sees Mrs. Jones in Clinic Eight for sudden loss of consciousness while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. Drake Rinaldi, a prominent member of the neurology faculty at the university saw Mrs. Jones last month. Dr. Howitzer performs a history including 3 HPI elements and 2 ROS, a detailed exam and has medical decision making of high complexity. The final diagnosis given is transient loss of consciousness. The patient makes a follow-up appointment to see Dr. Rinaldi in one week. What is the appropriate diagnosis and E/M code for this visit?
b.
99214, R55
Response Feedback:
Rationale: E/M Guidelines define an established patient as one who has received professional services from the provider or another provider of the same specialty who belongs to the same group practice within the past three years. The patient was seen the previous month by another member in the same group practice of the neurology department making this an established patient. The level of history is expanded problem focused defined by a brief HPI and an extended ROS. The exam is described as detailed and the MDM is of high complexity. For an established patient, you must meet or exceed two of the three key elements, making this a detailed visit. Two of the three key elements in this visit meet the requirements for 99214. Look in the ICD-10-CM Alphabetic Index for Loss (of)/consciousness, transient directing you to code R55. Verify code selection in the Tabular List.
Subjective: 6 year-old girl twisted her arm on the playground. She is seen in the ED complaining of pain in her wrist.
Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal
Assessment: Wrist sprain
Plan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement.
What is the E/M code for this visit?
a. 99281
Response Feedback:
Rationale: Emergency Department services must meet or exceed three of the three key components. The provider performed a problem focused history (brief HPI, no ROS, no PFSH), a problem focused exam (one body area is examined) and low MDM (for one new problem to the examiner, one data point for the X-ray, and low level of risk). The problem focused history and exam lead us to select 99281 as the appropriate code.
A 65 year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening.
CHIEF COMPLAINT: CHF
INTERVAL HISTORY: CHF symptoms worsened since yesterday.
Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I’m concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome.
REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins.
PHYSICAL EXAMINATION:
GENERAL: Mild respiratory distress at rest
VITAL SIGNS: BP 168/84, HR 58, temperature 98.1.
LUNGS: Worsening bibasilar crackles
CARDIOVASCULAR: RRR, no MRGs.
EXTREMITIES: Show worsening lower extremity edema.
LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.
IMPRESSION:
- Severe exacerbation of CHF
- Poorly controlled HTN
- Worsening ARF due to cardio-renal syndrome
PLAN: 1. Increase BUMEX to 2 mg IV Q6. 2. Give 500 mg IV DIURIL times one. 3. Re-check usual labs in a.m. Total time: 20 minutes.
What E/M Category is used for this visit?
b.
Subsequent Hospital Visit (99231-99233)
Response Feedback:
Rationale: This is a subsequent hospital visit which is reported with code range 99231-99233; because the patient was admitted in the hospital two days ago and the primary care physician has been seeing the patient since he has been admitted to the hospital. Initial Hospital Visit (99221-99223) is when the physician is admitting the patient to the hospital. Inpatient Consultation (99251-99255) is when the provider requests for another provider to see the patient to recommend care for a specific condition or to accept ongoing management for the patient’s condition. Established Patient Office/Outpatient Visit (99211-99215) is when the patient is being seen in the office setting, not the hospital.
A 37 year-old female is seen in the clinic for follow-up of lower extremity swelling.
HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide.
DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension.
Exam: Patient is in no acute distress.
ASSESSMENT:
1. Bilateral lower extremity swelling. This has resolved with diuretics; it may be secondary to problem #2.
2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist.
PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study.
d.
99212
Response Feedback:
Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Problem Focused (HPI Brief, ROS None, PFSH Pert), Exam Problem Focused, MDM Moderate (Management options: 1 stable problem, one new problem with workup; Data reviewed: lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported.
Dr. X asks Dr. Y to look at a 55 year-old male who is in a nursing facility for decubitus ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a detailed history from Dr. X since the patient is unable to provide a history. A detailed exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to the surgical suite for debridement of the ulcerations. Since the patient is unstable at the moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep monitoring the patient until he stabilizes. Written report is documented. What CPT® code is reported?
d.
99253
Response Feedback:
Rationale: Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing facility. According to CPT® guidelines: “The initial inpatient consultation codes (99251-99255), are to be used only once by the reporting provider for an individual hospital or nursing facility patient for a particular admission. These codes are to be reported for consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting.” A consultation is a type of service provided by a provider whose opinion or advice regarding evaluation and /or management of a specific problem is requested by another provider. The consulting provider performs the consultation, documents his or her opinion in the patient’s medical record, and communicates findings/recommendations by written report to the requesting provider or other appropriate source. Consultations require the documentation of three of three key components. The provider performed a detailed history, detailed exam and moderate MDM. The correct code is 99253.
