E&M Coding

Question 1

What category of E&M code would be needed for office or other outpatient services; these are codes used in ambulatory primary care and most other outpatient settings?

Answer 1

-Outpatient

Question 2

_____ Patient Visit (99201 – 99205): patient has not seen you or another provider in your group in 3 years

Answer 2

New

Question 3

_______ patient Visit (99211 – 99215): Patient has received professional services from you or someone in your group in the past 3 years

Answer 3

Established

Question 4

This category of E&M coding is used for services provided to patients on observation status in a hospital. (99217 – 99220)

Answer 4

Hospital Observation Services

Question 5

This category of E&M coding is used for services provided to patients while admitted to a hospital.

Answer 5

Hospital Inpatient services: 
Types: 
-Initial Hospital Care 
-Subsequent Care discharge care	
-Admit & disch same day

Question 6

_____ Hospital Care (99221 – 99223): first hospital inpatient encounter with the patient by the admitting physician when ____ included in the global surgical package; also known as the _________ note or H&P.

Answer 6

• Initial
• NOT
• Admission

Question 7

________ Care (99231 – 99233): follow up or daily visits when not included in the global surgical package

Answer 7

-Subsequent

Question 8

This category of E&M coding is used for evaluation and management services provided in an emergency department (99281 – 99285).

Answer 8

Emergency Services

-No distinction is made between new and established patients

Question 9

This category of E&M coding is used for provider visits to patients admitted in skilled nursing facilities.

Answer 9

Nursing home

• initial assessment 99301 – 99303
• subsequent 99311 – 99313
• discharge 99315 – 99316

Question 10

This category of E&M coding is used for provider visits to patients living in custodial care settings.

Answer 10

Rest Home

• new patient 99321 – 99323
• established patient 99331 – 99333

Question 11

This category of E&M coding is used for provider visits to patients’ homes.

Answer 11

Home Services

• new patient 99341 – 99345
• established patient 99347 - 99350

Question 12

Name some other categories of services that E&M coding recognizes?

Answer 12

include critical care (adult, pediatric, and neonatal), case management services, care plan oversight, newborn care, and special evaluation and management services.

Question 13

What category is the most important to focus on for out purposes?

Answer 13

Category 1 - Outpatient

Question 14

In the 5 digit E&M code, what does the 4th digit tell you?

Answer 14

Category (Outpatient, Inpatient, ER)

Question 15

What does the 5th and final digit of an E&M code tell you?

Answer 15

Determines the Level of Service provided

Question 16

To determine the level of service, the provider must consider what factors?

Answer 16

The primary factors of history, exam, and medical decision making.

Question 17

History and physical exam are rated using 4 descriptors, indicating the extent of evaluation done. What are they?

Answer 17

1) Problem focused (PF) - Least complex
2) Expanded problem focused (EPF)
3) Detailed (D)
4) Comprehensive (C) - Most complex

Question 18

What makes up a Problem Focused History?

Answer 18

-CC & Brief HPI (1 to 3 elements)

Question 19

What makes a History Expanded Problem Focused (EPF)?

Answer 19

• CC, Brief HPI

- problem-pertinent ROS: pertinent positives and negatives regarding associated symptoms in affected organ system

Question 20

What makes a History Detailed?

Answer 20

• CC, Extended HPI (4 or more elements)
• Extended ROS (2 to 9 systems)
• Pertinent PMH, FH, or SH (1 of 3)

Question 21

What makes the History Comprehensive?

Answer 21

• CC, Extended HPI
• complete ROS (10 systems)
• PMH, FH, SH (For NP: all 3 & For EP: 2 of 3)

Question 22

A ______ ______ exam is defined as “a limited examination of the affected body area or organ system.”

Answer 22

Problem Focused

-Examine only affected body area or organ system; Asthma example: Lungs

Question 23

An ________ ________ focused exam is defined as “a limited examination of the affected body area or organ system and other symptomatic or related organ systems.”

Answer 23

Expanded Problem Focused

-Asthma: Lungs + ENT or Heart

Question 24

A ________ exam is defined as “an extended examination of the affected body area(s) and other symptomatic or related organ system(s).”

Answer 24

Detailed

• Extended exam of affected body area (lungs) and related organ systems
• Exam of lungs, ENT, cardiovascular, and extremities for cyanosis.

Question 25

A _____________ exam is defined as “a general multi-system examination or a complete examination of a single organ system.”

Answer 25

Comprehensive

-Complete Multi-system exam

Question 26

What are the 3 elements considered in determining the complexity of medical decision-making?
(2 out of 3 must be met or exceeded before a level is chosen: Straight forward, Low, Mod. High complexity)

Answer 26

1) Number of diagnoses and management options to be considered
2) Amount and complexity of data reviewed
- Labs
- Prior records
- Consultant reports
3) Risk level: complications, morbidity, mortality

Question 27

The level of complexity of decision-making in a specific encounter is not determined by the __________ a patient carries. Comorbidities and __________ diseases are not considered in selecting a level of E&M services unless their presence significantly increases the _________ of the medical decision-making.

Answer 27

• Diagnosis
• Underlying diseases
• Complexity
  (i. e., if a patient presenting w/fever & cough also had coexisting diabetes and COPD, that would affect the complexity b/c it will affect how you treat!)

Question 28

Time is a ________ factor in determination of E&M codes. It is only used when counseling and/or coordination of care occupies more than ___% of the encounter (face-to-face time in the office setting).

Answer 28

• Secondary

- 50%

Question 29

What’s the term for coding for a lower level than the service they provide?

Answer 29

Undercoding

-Fraud

Question 30

Health maintenance visits, or “general check-ups” for healthy people, fall under the ___________ Medicine codes.

Answer 30

-Preventative

Question 31

If only a procedure is done, no ________ and _________ code is charged.

Answer 31

Evaluation & Management

Question 32

When more than one service is provided by the same clinician on the same day, _______ must be used.

Answer 32

Modifiers

-Procedure and E&M combo visits

Question 33

This is the most common modifier in primary care where significant, separately identifiable evaluation and management service by the same provider on the same day of the procedure or other service.

Answer 33

Modifier 25

-i.e., Preventative “well visit” that presented with an abnormal mole and biopsy was taken same day!