CPC Chapter 19- Evaluation and Management Review Questions

Question 1

Mr. Andrews, a 34-year-old male, visits Dr. Parker’s office at the request of Dr. Smith for a neurological consultation. He presents with complaints of weakness, numbness, and pain in his left hand and arm. Dr. Parker examines the patient and sends his recommendations and a written report back to Dr. Smith for the care of the patient. Which category or subcategory of evaluation and management codes would be selected for the visit to Dr. Parker?
A. Office visit, new patient
B. Office visit, established patient
C. Outpatient consultation
D. Case management services

Answer 1

C. Outpatient consultation

Rationale: Dr. Smith requests Dr. Parker to see Mr. Andrews for a neurologic consultation. Dr. Parker evaluates the patient and provides a written report to Dr. Smith with a recommendation. The requirements for a consultation have been met and an evaluation and management code from outpatient consultation would be selected.

Question 2

A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive checkup and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam?
A. Office visit, established patient
B. Preventive medicine, established patient
C. Subsequent hospital care
D. Preventive medicine, individual counseling

Answer 2

B. Preventive medicine, established patient

Rationale: The mother “takes her 2-year-old back to Dr. Denton” indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc.

Question 3

John, a 16-year-old male, is admitted by the hospitalist for observation after an ATV accident. The patient is discharged from observation by another provider the next day. What category or subcategory of evaluation and management codes would be selected for the hospitalist?
A. Office or Other Outpatient Services, New Patient
B. Emergency Department Services
C. Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services)
D. Initial Hospital Inpatient or Observation Care

Answer 3

D. Initial Hospital Inpatient or Observation Care

Rationale: The patient was admitted to observation by the Hospitalist physician. It is the initial visit by the hospitalist group for the hospital stay.

Question 4

Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove cancer from the spinal cord. He acted as a co-surgeon working with an orthopedic surgeon. Dr. Hedrick followed up with the patient during his rounds at the hospital the next day. From what category or subcategory of evaluation and management services would Dr. Hedrick’s follow-up visit be reported?
A. Outpatient visit, established patient
B. Inpatient consultation
C. Non-billable
D. Subsequent hospital care

Answer 4

C. Non-billable

Rationale: The follow-up visit from the neurosurgeon the day following surgery is bundled in the surgical procedure and is not billable. The visit is within the global period of the procedure.

Question 5

During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee. Her knee has been unstable since the incident and she decided to consult an orthopedist. She visits Dr. Howard, an orthopedist she has not seen before, to evaluate her knee pain. Dr. Howard’s diagnosis is a torn ACL. What category and subcategory of evaluation and management code would be selected for the visit to Dr. Howard?
A. Office visit, new patient
B. Office visit, established patient
C. Outpatient consultation
D. Preventive visit, new patient

Answer 5

A. Office visit, new patient

Rationale: Consultations performed at the request of a patient are coded using office visit codes. Because the patient has not seen Dr. Howard before, this would be considered a new patient visit.

Question 6

ESTABLISHED PATIENT OFFICE VISIT

DOS: 05/09/X1

CHIEF COMPLAINT: Left tibia fracture.

HISTORY OF PRESENT ILLNESS: Patient is a 13-year-old male we first saw on 04/24/X1. He was noted to have been injured when he jumped and fell while running down a hill. He sustained a Salter-Harris II physeal fracture of the distal tibia. He is currently non-weight bearing in a short-leg cast. He has been compliant with his activity modifications.

PHYSICAL EXAMINATION: He is intact to sensation. His capillary refill of the toes remains stable. There is no skin breakdown at the proximal or distal aspect of the cast. The cast is intact.

ANCILLARY STUDIES: Radiographs ordered, performed, and billed in our office of the left ankle May 08, 20XX show good alignment and positioning of the fracture. Growth plate is stable.

IMPRESSION: Left distal tibia fracture.

PLAN: He will continue with the use of his cast, maintain non-weight bearing status. Return for reassessment with new X-ray in two weeks. Cast care instructions are once again being reviewed.

What E/M code is reported?
A. 99212
B. 99213
C. 99214
D. 99215

Answer 6

B. 99213

Rationale: Established Patient

Number and Complexity of Problems – One acute uncomplicated illness or injury – Low

Amount and/or Complexity of Data to be Reviewed and Analyzed – The order of the new X-ray can be counted. If the X-Ray is performed and reported by the office, there is no credit given here. Either way, the result is Minimal to None for Data.

Risk – Non-weight bearing, cast care – Low

Question 7

NEW PATIENT OFFICE VISIT

CHIEF COMPLAINT: Low back pain with radiating pain into the legs.

HISTORY OF PRESENT ILLNESS: A 78-year-old female with long-standing back pain. She is noted to have undergone previous epidurals. She has been diagnosed with spinal stenosis for approximately 10 years. She denies bowel or bladder dysfunction or saddle anesthesia. She offers a weakness of the extremity and numbness. She offers no unexpected weight loss, no recent trauma. She denies previous back surgery. She is a new patient to our office.

CURRENT MEDICATIONS: Lisinopril, Lovastatin, glipizide, Arimidex, Naproxen, Neurontin, Xalatan, multivitamin.

ALLERGIES: Codeine.

PAST MEDICAL HISTORY: Breast cancer, hypertension, diabetes, prior history of spinal stenosis.

REVIEW OF SYSTEMS: Denies any cardiac arrhythmia or unstable angina. No pulmonary disorders. Denies thyroid disease. No renal dysfunction. No history of stroke or seizure. She is without any unexpected weight loss or constitutional signs of infection.

SOCIAL HISTORY: She is ambulatory without assist device. Denies tobacco and alcohol use.

FAMILY HISTORY: Diabetes and cancer.

PHYSICAL EXAMINATION: Side-to-side comparison shows no asymmetry, no pronounced atrophy. She has a pronounced straight leg raise on the right and also a contralateral straight leg raise on the left, but her discomfort is to a lesser degree.

Reflexes are symmetric. Motor strength is noted to be 5/5 with ankle dorsi and plantar flexion, great toe extension, knee flexion/extension, hip abduction. She has 4/5 motor strength with hip flexion. Her hips are supple on examination. She has decreased sensation to L4-L5 level.

ANCILLARY STUDIES: Independent interpretation of previous MRI from the hospital November 20XX shows evidence of spinal stenosis at L3-4, L4-5, and 5-S1. There is neural foraminal narrowing at these levels. Findings are most noted at L4-5. In addition, there is facet hypertrophy and ligamentous thickening. Cord maintained a normal signal.

IMPRESSION: Spinal stenosis with radicular leg pain.

PLAN: A repeat of the MRI will be obtained. She will return for reassessment following this study. Likely begin another course of epidural steroids. I have also recommended physical therapy. Further recommendations are pending her MRI.

What E/M code is reported?
A. 99202
B. 99203
C. 99204
D. 99205

Answer 7

C. 99204

Rationale: New Patient

Number and Complexity of Problems – One chronic illness with exacerbation, progression, or side effects of treatment – Moderate (The definition for a chronic illness with exacerbation, progression, or side effects of treatment include a chronic illness that is poorly controlled. In this case, the radiating pain in the legs is a progression of spinal stenosis and the provider will treat this with epidural steroids and physical therapy depending on the new MRI results.)

Amount and/or Complexity of Data to be Reviewed and Analyzed – Independent review of MRI performed at the hospital (one Category 2 item) and order of new MRI (one Category 1 item) - Moderate

Risk – Minor surgery with no additional risk factors (epidural steroids) and physical therapy – Low

Question 8

Patient is seen in the ED for a migraine. She is experiencing nausea with vomiting and decreased appetite. Blurry vision. Has had a low-grade fever. The pain is rated 9 out of 10 and is not responding to oral medication.

Physical exam: General appearance: Mild distress. 99.6 BP 110/60 Resp 18
Skin: Warm. Dry. No pallor. No rash. Good skin turgor.
Facial: No bruises, no swelling, no tenderness.
Scalp: No swelling, no deformity, no tenderness.
Neck: Trachea midline.
Cognitive function: Within normal limits.
Best response: Within normal limits.
Speech: Within normal limits.
Sensation: Within normal limits.
Motor strength: Within normal limits.
Extinction-neglect: Negative.
Reflexes: Within normal limits.
Cerebellar test: Within normal limits.
Assessment: Migraine headache - intractable, R/O viral infection, meningitis
Plan: She will be admitted by the internist. Order CT of head and lumbar puncture.

What E/M code is reported?
A. 99282
B. 99283
C. 99284
D. 99285

Answer 8

B. 99283

Rationale: The patient is seen in the ED. The ED Service codes do not differentiate between new and established patients. The patient is admitted to the hospital by another physician.

Number and Complexity of Problems – The provider is uncertain what is causing the intractable migraine and has ordered a CT and a lumbar puncture to rule out a viral infection or meningitis. This is also requiring hospital admission - Moderate

Amount and/or Complexity of Data to be Reviewed and Analyzed – The provider ordered a CT - Limited

Risk – minor surgery (lumbar puncture) and CT Scan of the head – Low

The documentation supports 99283.

Question 9

Mrs. Standerfer’s family physician visits her in the nursing home after a spell of dizziness and confusion reported by the staff at the nursing home. Her family physician has seen her several times during this admission. She sat down after lunch and stated she was dizzy. She slept for two hours after the spell. She states she is doing much better now. She has a known history of electrolyte imbalance and is on fluid restriction at the nursing home. She has not experienced any chest pain, dyspnea, unexplained weight changes, or intolerance to heat or cold. No complaints of head or neck pain. During the exam, the physician takes her BP both supine and standing, and notes her pulse and temperature. A detailed exam of the eyes, ears, nose, and throat is performed along with a detailed neurological exam. The physician orders an electrolyte panel to determine if her electrolytes are out of balance again.

What is the appropriate E/M code for this visit?
A. 99307
B. 99308
C. 99309
D. 99310

Answer 9

B. 99308

Rationale: The patient is seen in the nursing home by her family physician. Because this provider has seen this patient before during the nursing facility admission, this is reported as a subsequent nursing facility service.

Number and Complexity of Problems – The patient is suspected of having an exacerbation of a chronic problem (electrolyte imbalance) - Moderate

Amount and/or Complexity of Data to be Reviewed and Analyzed – The provider ordered an electrolyte panel - Minimal

Risk – the patient is feeling fine and no medication adjustments are made - Low

The documentation supports 99308.

Question 10

A 45-year-old patient is seeing the neurologist, Dr. Williams, at the request of his family physician to evaluate complaints of weakness, numbness, and pain in his left hand and arm. The pain started last year after rocks fell on him while mining. He still has significant, sharp, burning wrist pain and reports the problems are continuing to get worse. He is limited in his job as a machinist for a mining company due to the pain and numbness. He has no swelling in his hand, no neck pain, or radiating pain.

His past medical history is negative for significant diseases. He has had carpal tunnel surgery. He has a family history of hypertension, heart disease, and stroke. He is married with children and smokes one pack of cigarettes/day.

A detailed exam is performed of the mental status, cranial nerves, motor nerves, DTRs, sensory nerves, and head and neck.

After performing an EMG and nerve conduction study, Dr. Williams determines the patient has left ulnar neuropathy at the cubital tunnel region, as well as an ongoing carpal tunnel syndrome. Repeat carpal tunnel surgery is recommended, along with a possible cubital tunnel surgical procedure. If the patient does not have surgery, he risks permanent nerve damage. A report is sent back to the physician requesting the consult.

What is the appropriate E/M consultation code for this visit?
A. 99242
B. 99243
C. 99244
D. 992445

Answer 10

B. 99243

Rationale: The patient is seeing a neurologist at the request of his family physician to evaluate and make recommendations for his neurological symptoms. The provider sends a report back to the family physician. This is a consultation.

The documentation supports a 99243.

Number and Complexity of Problems – Acute uncomplicated injury – Low

Amount and/or Complexity of Data to be Reviewed and Analyzed – None. The provider performs an EMG and nerve conduction study and will bill for these services, so they are not included in leveling the medical decision making.

Risk – elective major surgery with no mention of potential risk factors for the surgery – Moderate

Question 11

Which appendix in the CPT® code book lists the summary of the add-on codes?
A. Appendix L
B. Appendix A
C. Appendix D
D. Appendix B

Answer 11

C. Appendix D

Rationale: Appendix D of the CPT® code book lists the summary of CPT® add-on codes. The appendix may be used in addition to the E/M code descriptors. Add-on codes have a plus symbol in front of the code.

Question 12

A patient is seen for hypertension. Her provider has her on prescriptions, but her blood pressure is not yet at goal. The patient does not exhibit any symptoms. When referring to the number and complexity of problems addressed, what type of problem is this considered?
A. Acute or chronic illness or injury that poses a threat to life or bodily functions.
B. Chronic illness with exacerbation, progression, or side effects of treatment.
C. Chronic illness with severe exacerbation, progression, or side effects of treatment.
D. Stable, chronic illness

Answer 12

B. Chronic illness with exacerbation, progression, or side effects of treatment.

Rationale: According to the CPT® E/M guidelines, a stable, chronic illness is a chronic illness that is at goal. The patient’s hypertension is not yet at goal. Even though there are no symptoms exhibited, this is considered a chronic illness with exacerbation, progression, or side effects of treatment.

Question 13

A provider admits Mrs. Smith to the hospital. She is there for five days. The provider sees her each day she’s in the hospital. What subcategory of E/M codes would be used for days two, three and four?
A. Subsequent Hospital Care
B. Initial Hospital Care
C. Skilled Nursing Facility
D. Office or Other Outpatient Services; Established patient

Answer 13

A. Subsequent Hospital Care

Rationale: Codes from the Subsequent Hospital Care subcategory would be used for days two, three and four. The code for the first day would be from the Initial Hospital Care subcategory. Day five could be reported with either subsequent hospital care or hospital care discharge depending on the role of the provider.

Question 14

What modifier is used to report an evaluation and management service mandated by a court order?
A. 57
B. 24
C. 62
D. 32

Answer 14

D. 32

Rationale: Modifier 32 is used for services related to mandated consultation and/or related services by a third-party payer, governmental, legislative or regulatory requirements.

Question 15

A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A., but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?
A. Office consultation
B. New patient office visit
C. Preventive medicine visit
D. Established patient office visit

Answer 15

D. Established patient office visit

Rationale: According to the E/M Guideline for New and Established Patient, when a provider is on call or covering for another provider, the patient’s encounter will be classified as it would have been by the provider who is not available. In this instance, Dr. B would report an established patient office visit.

Question 16

A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist, and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient’s family is not present. What CPT® code is reported?
A. 99252
B. 99368
C. 99367
D. 99366

Answer 16

C. 99367

Rationale: In CPT® Index, look for Conference/Interdisciplinary Medical Team and you are directed to codes 99367, 99368. Code 99367 is reported for a medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. All providers listed in the scenario are physicians; 99367 is the correct code.

Question 17

A newborn baby is delivered at the hospital. Immediately after birth, the pediatrician is present in the delivery room to monitor the baby’s condition due to cardiac distress. The pediatrician performs cardiopulmonary resuscitation to stabilize the baby’s condition. What E/M coding is reported?
A. 99460
B. 99465
C. 99464, 99465
D. 99464

Answer 17

B. 99465

Rationale: In the CPT® Index, look for Newborn Care/Resuscitation, referring you to 99465. There is a parenthetical note under 99465 not to report 99465 with 99464. Because CPR is provided to the newborn, 99465 is the correct code to report.

Question 18

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 medically appropriate history and exam. Medical decision making is 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?
A. 99215, R55
B. 99202, R40.1
C. 99203, R55
D. 99214, R40.1

Answer 18

A. 99215, R55

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. A medically appropriate history and exam are documented. MDM is of high complexity. Based on CPT® E/M guidelines, this supports 99215.

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.

Question 19

The EMS brought a 31-year-old motor vehicle accident patient to the Emergency Department. The provider determines the patient has multiple internal injuries and needs immediate surgery. What level is reported for risk of complication and/or morbidity or mortality of patient management?
A. Straightforward
B. High
C. Moderate
D. Low

Answer 19

B. High

Rationale: The MDM table provided in the CPT® code book for High under Risk of Complication gives an example of decision regarding emergency major surgery.

Question 20

A provider visits Mr. Smith’s home monthly. Today, the provider performs a medically appropriate history and examination. The provider orders a CBC, blood iron level, level for B12, and folate lab tests. What is the level for the amount and/or complexity of data to be reviewed and analyzed?
A. Low
B. Moderate
C. High
D. Straightforward

Answer 20

B. Moderate

Rationale: The provider ordered four unique lab tests. The amount of complexity of data will be moderate.

Question 21

A 10-year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs a history and exam and treats the patient for a URI with low medical decision making. What CPT® coding is reported for this visit?
A. 99393-25, 99213
B. 99393, 99213-25
C. 99213
D. 99393

Answer 21

B. 99393, 99213-25

Rationale: The physical exam code is selected from the Preventive Medicine Services and selected based on whether the patient is new or established and by age. The pediatrician also evaluates and treats the URI. The additional work for the URI allows us to report an established patient office visit. Modifier 25 is appended to the office visit to show it is a significant and separately identifiable service from the preventive visit.

Question 22

A patient is discharged from the hospital following a heart attack. The patient is initially contacted two business days after the discharge at his home. The patient’s primary care physician manages the care of the patient during the transition to home care. The physician conducts a face-to-face visit on day 13 after discharge to home. During this visit, the physician reviews the patient’s hospital records, reconciles medications, and develops a care plan for the patient’s recovery. A moderate level of MDM is documented. What E/M code is reported?
A. 99344
B. 99495
C. 99305
D. 99214

Answer 22

B. 99495

Rationale: The patient was discharged from the hospital and his primary care physician is seeing him within 14 days for managing the patient’s care during the transition to home. Codes 99214, 99344, and 99305 are reported only for a one-day visit, not for a period of days. In the CPT® Index, look for Evaluation and Management Services/Transitional Care. Refer to the code description given for code 99495 in the CPT® code book.

Question 23

A 77-year-old Medicare beneficiary has a digital rectal examination for prostate cancer screening and the provider orders a PSA. How would this be reported?
A. 99397-25, 45990
B. G0027
C. 993.87-25, 45990
D. G0102

Answer 23

D. G0102

Rationale: CMS has very specific guidelines on eligibility and coding of preventive services. There is no specific CPT® code for a digital rectal exam. Code 45990 is a diagnostic exam that includes a diagnostic anoscopy and rigid proctoscopy. Neither service is documented nor is it stated that the patient received an annual exam. The service provided is best represented by HCPCS code G0102.

Question 24

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 a medically appropriate 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?
A. 99203
B. 99348
C. 99213
D. 99342

Answer 24

B. 99348

Rationale: According to CPT® E/M guidelines, Home Services codes (99341-99350) are used to report evaluation and management services provided in a private residence. This is an established patient to the provider. The provider performed a low MDM resulting is code 99348.

Question 25

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. A medically appropriate exam is performed and the MDM is high. The patient was stabilized and transferred to ICU under a different provider. The ED provider documents total critical care time 25 minutes. What CPT® coding is reported?
A. 99285
B. 99291
C. 99223-25, 99291
D. 99285-25, 99291

Answer 25

A. 99285

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 MDM is high. The correct code is 99285.

Question 26

A 5-year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported?
A. 92950, 99291-25, 36556, 31500
B. 92950, 99291-25, 36556, 31603
C. 92950, 99285-25, 36556, 31500
D. 92950, 99291

Answer 26

A. 92950, 99291-25, 36556, 31500

Rationale: ED provider documents an amount of time spent with this critical patient. According to CPT® guidelines: “The critical care codes 99291 and 99292 are used to report the total duration of time spent by a provider providing critical care services to a critically ill or critically injured patient. Time spent with individual patient is recorded in the patient’s record.” According to CPT® guidelines: “Services such as endotracheal intubation (31500) and cardiopulmonary resuscitation (92950) are not included in the critical care codes. Therefore, they can be coded separately in addition to critical care services if the critical care is a significant, separately identifiable service, and is reported with modifier -25. The time spent performing these other services, for example endotracheal intubation, is excluded from the determination of the time spent providing critical care.” In the CPT® Index look for Cardiopulmonary Resuscitation (CPR) referring you to code 92950. Review code to verify accuracy. In the CPT® Index look for Catheterization/Central referring you to codes 36555-36566. 36556 is the correct code because the patient is 5 years of age and there is no indication the CVC was tunneled. In the CPT® Index look for Intubation/Endotracheal Tube referring you to code 31500. Review code to verify accuracy.

Question 27

An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. Exam was performed. Provider reviewed the complete blood count lab from the hospital and personally viewed and interpreted a recent chest X-ray that shows the right lung with infiltrates. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and follow up X-ray. What CPT® code is reported?
A. 99242
B. 99213
C. 99349
D. 99214

Answer 27

D. 99214

Rationale: The patient was seen in the clinic, which is an outpatient service. Medical decision making is the determining factor for selecting E/M level. MDM level is moderate:

Number and Complexity of Problems Addressed at the Encounter – Moderate (acute illness with systemic symptoms)

Amount and/or Complexity of Data to be Reviewed and Analyzed – Moderate (review of lab from the hospital and independent visualization of the chest X-ray)

Risk of Complications and/or Morbidity of Patient Management – Moderate (prescription drug management)

MDM is moderate, reported using 99214.

Question 28

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
B. 99283
C. 99221
D. 99284

Answer 28

B. 99283

Rationale: The provider performed a medically appropriate history and exam with a low MDM.

Number and Complexity of Problems Addressed at the Encounter – Low (acute uncomplicated injury)

Amount and /or Complexity of Data to be Reviewed and Analyzed – Minimal (one unique test [X-ray])

Risk of Complications and/or Morbidity of Patient Management – Low (over-the-counter medication)

Low MDM is 99283.

Question 29

Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk, but her mother has returned to work and is using a breast pump but has not seemed to produce enough milk.

PHYSICAL EXAM: Weight 12 lbs. 11 oz., Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week.

ASSESSMENT
Four-month-old well check
Cold
Mild thrush
Diaper rash
PLAN:
Okay to advance to baby foods
Okay to supplement with Similac
Nystatin suspension for the thrush and creams for the diaper rash if it recurs
Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polio

What E/M code(s) is/are reported?
A. 99213
B. 99212
C. 99391, 99212-25
D. 99391

Answer 29

D. 99391

Rationale: Documentation states the encounter is for a checkup, which is a Preventive Medicine Service. In the CPT® Index look for Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A for a description of modifier 25.

Question 30

A 37-year-old female is seen in the clinic for follow-up of lower extremity swelling. She has had this issue for the past six months.

HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide.

DATA REVIEW: I reviewed her CBC lab.

EXAM: Patient is in no acute distress.

ASSESSMENT:
1. Bilateral lower extremity swelling. This has resolved with diuretics.

PLAN: Will order an echocardiogram and kidney function lab test. Refill prescription. Return in 2 months.
A. 99215
B. 99213
C. 99214
D. 99212

Answer 30

B. 99213

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. MDM for this visit is low.

Number and Complexity of Problems Addressed at the encounter – Low (one stable chronic illness; extremity swelling which has gotten better with medication)

Amount and/or Complexity of Data to be Reviewed and Analyzed – Limited (two unique tests ordered [echocardiogram and kidney function lab test]. The CBC reviewed is not counted. This is a follow-up examination; the CBC was ordered at the last visit and will not be counted when reviewed in a follow-up visit.)

Risk of Complications and/or Morbidity or Mortality of Patient Management: Moderate (Prescription drug management)

MDM Level is low – 99213.

Question 31

An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?
A. 99471-25, 94610, 36510
B. 99291
C. 99471
D. 99291-25, 31500, 36510, 94610

Answer 31

D. 99291-25, 31500, 36510, 94610

Rationale: When neonatal services are provided in the outpatient setting, Inpatient Neonatal Critical Care guidelines direct the coder to use critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 each additional 30 minutes (List separately in addition to code for primary service). Care is documented as lasting 45 minutes with the physician in constant attendance. The physician also administered intrapulmonary surfactant (94610), placed an umbilical vein line (36510) and intubated the patient (31500). According to CPT® Critical Care Services guidelines these procedures are not included in the critical care codes. Therefore, they can be reported separately in addition to critical care services with modifier 25 appended to code 99291.

Question 32

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:
1. Severe exacerbation of CHF
2. Poorly controlled HTN
3. 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?
A. Initial Hospital or Observation Visit (99221-99223)
B. Initial Hospital or Observation Visit (99221-99223)
C. Established Patient Office/Outpatient Visit (99211-99215)
D. Subsequent Hospital or Observation Visit (99231-99233)

Answer 32

D. Subsequent Hospital or Observation Visit (99231-99233)

Rationale: This is a subsequent hospital visit which is reported with code range 99231-99233. 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 or Observation Visit (99221-99223) is when the doctor is initially admitting the patient to the hospital. Inpatient Consultation (99252-99255) 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.

Question 33

ICU - CC: Multi-system organ failure
INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.

PHYSICAL EXAM: BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.
LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.

IMPRESSION
Hypoxic respiratory failure
Community acquired pneumonia
Septic shock
Non-oliguric acute renal failure

PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6H
Follow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90
Usual labs ordered for tomorrow.
Critical care time: 35 minutes

What CPT® code(s) is/are reported?
A. 99291
B. 99291, 99292
C. 99233
D. 99232

Answer 33

A. 99291

Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient’s condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.

Question 34

New Patient History & Physical

CHIEF COMPLAINT: Right chronic inguinal hernia.

HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago, in the shower, he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country.

PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.

MEDICATIONS: Advair.

ALLERGIES: None.

REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.
GENERAL APPEARANCE: He is a very muscular well-built man in no distress.
SKIN: Normal.
LYMPH NODES: None.
HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt.
CHEST: Clear to auscultation.
HEART: Regular rhythm with no murmur.
ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal.

IMPRESSION: Right chronic indirect inguinal hernia.

PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. He was cautioned on the fact this could become an emergent situation if this becomes incarcerated. I gave him the scheduling number, and he will call and arrange the operation.

What CPT® and ICD-10-CM codes are reported?
A. 99203, K40.90
B. 99205, K46.9
C. 99202, K46.9
D. 99204, K40.90

Answer 34

D. 99204, K40.90

Rationale: This is a new patient office visit which is coded from range 99202-99205. Medical decision making is the determining factor for selecting E/M level.

MDM is moderate:

Number and Complexity of Problems Addressed at the Encounter – Moderate (chronic condition with exacerbation)

Amount and/or Complexity of Data to be Reviewed and Analyzed – None

Risk of Complications and/or Morbidity of Patient Management – Moderate (elective major surgery without identified patient or procedure risk factors)

MDM is moderate, reported using 99204.

In the ICD-10-CM Alphabetic Index look for Hernia, hernial/inguinal (indirect). Indirect is a nonessential modifier listed for Hernia, hernial/inguinal. You are directed to K40.90. Verify code in the Tabular List.

Question 35

A 90-year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a history and exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. After 10 hrs of observation, he will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?
A. 99238
B. 99221
C. 99235
D. 99236

Answer 35

C. 99235

Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate.” MDM is moderate:

Number and Complexity of Problems Addressed at the Encounter – Moderate (undiagnosed new problem with uncertain prognosis)

Amount and/or Complexity of Data to be Reviewed and Analyzed – None

Risk of Complications and/or Morbidity of Patient Management – Moderate (drug management)

Moderate MDM is 99235.