Chapter 11; Evaluation and Management (E/M) Services

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the history level on the following code: 99204

Comprehensive

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the history level on the following code: 99205

Comprehensive

The levels of service are based on key components and what factors?

Contributory

When a physician arranges for other services to be provided to the patient, this is considered what type of contributory factor?

Coordination of care

Contributory factors

Counseling, coordination of care, nature of presenting problem, and time.

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the examination level on the following code: 99203

Detailed

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the history level on the following code: 99203

Detailed

CMS developed a set of standards for documentation of E/M services which are called _____________

Documentation guidelines

What patient status is assigned to an encounter that has been seen by the same specialty within the past 3 years?

Established

Newborn care

Evaluation and determination of care for a newborn infant

Newborn care

Evaluation and determination of care management of a newly born infant.

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the examination level on the following code: 99202

Expanded problem focused

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the history level on the following code: 99202

Expanded problem focused

Locate the subsection office and other outpatient services in the CPT, then the category new patient in the E/M section to answer the following question: Each code represents a different level of service. How many codes are listed under Office or Other Outpatient Services for a new patient?

Five

Locate the subsection office and other outpatient services in the CPT, then the category new patient in the E/M section to answer the following question: How many codes are listed for the established patient in the Office or Other Outpatient Services category?

Five

Indicate whether the presenting problem to the severity level in the patient: minimal, self-limited, low, moderate, or high. Eighty-six-year-old woman who has a history of chronic obstructive pulmonary disease (COPD) and is oxygen-dependent comes in because of dizziness and weakness. Diagnosis is acute exacerbation of COPD. What is the level of the presenting problem and the diagnosis code?

High, J44.1, Z99.81

Locate the subsection office and other outpatient services in the CPT, then the category new patient in the E/M section to answer the following question: Where is the place of service?

Office or in an outpatient or other ambulatory facility

Locate the subsection office and other outpatient services in the CPT, then the category new patient in the E/M section to answer the following question: What is the type of service?

Office visit or other outpatient service

Inpatient

One who has been formally admitted to an acute health care facility

Established patient

One who has received services from the physician or another physician in the same group within the last 3 years

The last subsection in the E/M section describing an unlisted code is what type of evaluation and management services?

Other

Are observation codes 99218-99220 and 99224-99226 reported for inpatient or outpatient services?

Outpatient

Office, hospital, emergency department, and nursing home locations describe what factor in code assignments?

Place of Service

A general multi-system exam that includes one to five elements identified by a bullet in on or more organ system or bod areas according to 1995 documentation guidelines is a(n) _____________________ __________________ examination.

Problem focused

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the examination level on the following code: 99201

Problem focused

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the history level on the following code: 99201

Problem focused

List two types of service and CPT codes for the services that are bundled into critical care services, such as: Chest x-rays 71045-71048.

Pulse Oximetry (94760, 94761, 94762) Ventilator Management (94002-94004, 94660, 94662)

Indicate whether the presenting problem to the severity level in the patient: minimal, self-limited, low, moderate, or high. Four-year-old female established patient presents with slight pain in right ear, of 2 days' duration. Physician diagnosed a minor infection and prescribed antibiotic for acute exudative otitis media. What is the level of the presenting problem and the diagnosis code?

Self-limited, H65.191

What is the one criterion for selecting a hospital discharge day management code?

Time

Some history elements may be documented by ancillary staff or the patient. True or false?

True

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the examination level on the following code: 99204

Comprehensive

Using the CPT manual, locate the Office or Other Outpatient Services subsection, New Patient category, to identify the examination level on the following code: 99205

Comprehensive

Is the following a body area (BA) or organ system (OS): Arm

BA

Is the following a body area (BA) or organ system (OS): Breasts

BA

Is the following a body area (BA) or organ system (OS): Head

BA

Is the following a body area (BA) or organ system (OS): Neck

BA

Is the following a body area (BA) or organ system (OS): Thorax, anterior and posterior

BA

Is the following a body area (BA) or organ system (OS): Neurologic

OS

Is the following a body area (BA) or organ system (OS): Nose

OS

Is the following a body area (BA) or organ system (OS): Psychiatric

OS

Is the following a body area (BA) or organ system (OS): Skin

OS

Is the following a body area (BA) or organ system (OS): Throat

OS

Is the following a body area (BA) or organ system (OS): Vagina

OS

The criteria required to report a consultation include: _______________ from the attending to the consultant to see the patient, evaluation of the patient by the consultant and a ________________ back to the attending of the findings and recommendations of the consultant.

30 minutes or less, more than 30 minutes

Locate the subsection office and other outpatient services in the CPT, then the category new patient in the E/M section to answer the following question: What is the first code number listed under the subheading New Patient?

99201

A 4-year-old new patient presents for the removal of sutures from an appendectomy incision made 10 days earlier in another city. The physician conducts a brief history and examination prior to removing the stitches. What is the CPT code and the diagnosis code?

99201, Z48.02

A 41-year-old woman, new to the office, complains of headache and rhinitis of 4 days' duration. The patient states that she has had a problem with her allergies during this season for years. An expanded problem-focused history and examination are done. Straightforward MDM complexity. The diagnosis was grass pollen allergy. What is the CPT code and diagnosis code?

99202, J30.1

A new patient's record states that an initial office visit was made for the evaluation and management of a 48-year-old male with recurrent low back pain from a herniated disc, with pain radiating to the leg (myelopathy). A detailed history and a detailed examination were performed. Using this information identify the following factor: The patient record indicates that a detailed history was taken and a detailed examination was performed. When this is combined with the level of MDM complexity you arrived at for this patient, What is the correct CPT code for this case? What is the ICD-10-CM Code?

99203, M51.06

A new patient, a 10-year-old boy, is brought in by his father for a knee injury sustained in a hockey game. The knee is swollen and the patient is in apparent pain. A detailed history and examination are obtained. A diagnosis of medial collateral sprain of the right knee is made. Low MDM complexity. What is the CPT code and the diagnosis codes?

99203, S83.411A, Y93.22

A 53-year-old new patient presents for an initial office visit to discuss a surgical vasectomy for sterilization. The history and examination are detailed and the MDM is of low complexity. What is the CPT code and the diagnosis code?

99203, Z30.09

A 23-year-old man who is a new patient has an initial office visit for severe depression (report as first listed diagnosis) that has led to frequent thoughts of suicide in the past several weeks and is acute today. More than an hour is spent discussing the patient's problems and options. Past medical and family history is negative. The social history reveals that the patient suffers from sleeplessness (report as additional diagnosis); smokes between two and two and a half packs of unfiltered cigarettes a day and has for 5 years (report as tobacco abuse); drinks 10 to 12 cups of coffee; and denies current use of drugs. (The actual patient record continues and indicates that a comprehensive history and examination was conducted; high MDM complexity.) What is the CPT code and diagnosis codes?

99205, F32.9, R45.851, G47.00, F17.210

What CPT code reports services provided in an office for which the physician may not be present?

99211

A 17-year-old football player comes to the clinic for a 50 mg gold injection for a left anterior cruciate knee sprain that occurred last week. The injection was given by the nurse. Only the nurse sees this established patient. (Code only the E/M service and diagnosis.) What is the CPT code and the diagnosis code?

99211, S83.512D

A 42-year-old established patient presents for an office visit with complaints of severe vaginal itching and moderate pain. During the expanded problem focused history, the patient states that several weeks earlier she had noted slight itching, which has increased in severity. Yesterday, she noted a lesion on her genitalia. Burning and painful urination have increased over past 5 days accompanied by rectal itching. She has tried a variety of over-the-counter ointments and creams, which induced no improvement. The patient states that she has had several yeast infections in the past that had been successfully treated by her previous physician. Personal history indicates several prior urinary infections. No discharge noted. A problem focused examination of the external genitalia reveals a lesion, which had previously ruptured, located on the vulva. Bacterial and viral smears are done. The MDM is straightforward. The patient is advised that the smears would be back in 24 hours and that a treatment plan would be developed based on the reports. (The smear was positive for a bacterial infection, for which antibiotics were prescribed.) What is the CPT code?

99212

An established 31-year-old patient presents with an irritated and infected skin tag. A problem focused history and examination are done. MDM complexity is low. What is the CPT code and the diagnosis code?

99212, L91.8

An established 48-year-old woman has had diarrhea for the past 5 days. Her temperature is 101 degrees Fahrenheit. An expanded problem focused history and examination are done. MDM complexity is low. What is the CPT code and the diagnosis code?

99213, R19.7

A 61-year-old established patient is seen for medication management of malaise and fatigue produced by hypertension medication. An expanded problem focused history and examination are done, and the MDM is of moderate complexity. What is the CPT code and the diagnosis codes?

99213, R53.81, R53.83, T46.5X5A, I10

A 53-year-old established patient complains of frequent fainting. The history and examination are comprehensive, and the MDM is of high complexity. What is the CPT code and the diagnosis code?

99215, R55

Admission

Attention to an acute illness or injury that results in hospitalization

Is the following a body area (BA) or organ system (OS): Abdomen

BA

A patient was in an automobile accident and is complaining of a minor headache and no other apparent injuries. History gathered from bystanders state that patient was not wearing a seat belt and hit his head on the windshield. A 15-minute loss of consciousness was noted. The patient was diagnosed with a concussion. The patient was then admitted for 24-hour observation to rule out head injury. A comprehensive history and examination were performed. The MDM was of moderate complexity. What is the CPT code and the diagnosis codes?

99219, S06.0X1A, V49.9XXA

Counseling

A discussion with a patient and/or family.

Office visit

A face-to-face encounter in an office between the physician and patient

New patient

A patient who has not received professional services from a physician or another physician of the exact same specialty and subspecialty in the same group within the last 3 years.

Consultation

Advice or opinion from one physician to another physician

Indicate whether the presenting problem to the severity level in the patient: minimal, self-limited, low, moderate, or high. Established patient, 71 years old, with shortness of breath on exertion and a history of congestive cardiomyopathy. What is the level of the presenting problem and the diagnosis codes? (hint: shortness of breath; cardiomyopathy, congestive)

High, R06.02, I42.0

Subjective information given by the patient is part of what key components and what factors?

History

This status is assigned to a patient who has been formally admitted to a health care facility.

Inpatient

A new patient's record states that an initial office visit was made for the evaluation and management of a 48-year-old male with recurrent low back pain from a herniated disc, with pain radiating to the leg (myelopathy). A detailed history and a detailed examination were performed. Using this information identify the following factor: Data to review in order to provide service. (Data can be minimal/none, limited, moderate, or extensive.) Only the current record is available.

Limited

A new patient's record states that an initial office visit was made for the evaluation and management of a 48-year-old male with recurrent low back pain from a herniated disc, with pain radiating to the leg (myelopathy). A detailed history and a detailed examination were performed. Using this information identify the following factor: Diagnosis and management options for recurrent low back pain radiating to the leg. (Options can be minimal, limited, multiple, or extensive.)

Limited

A new patient's record states that an initial office visit was made for the evaluation and management of a 48-year-old male with recurrent low back pain from a herniated disc, with pain radiating to the leg (myelopathy). A detailed history and a detailed examination were performed. Using this information identify the following factor: Two of the three elements have been met to qualify this patient for what level of MDM complexity? (Complexity can be straightforward, low, moderate, or high.)

Low

Documented observations by the physician about the patient's complaint or problem is considered what type of information?

Objective

A 68-year-old female established patient presents to the office today with a "cold" of 9 days' duration. Patient reports that she has had a dry, hacking cough and nasal congestion for the past 6 days and a fever for the past 3 days. She states that she is unable to sleep due to the cough, fever, and aching. She appears to be in minor distress. Personal and family history are negative for respiratory problems. Temperature is 100 degrees Fahrenheit; blood pressure 150/90; pulse 93 and regular. Lungs clear to percussion and auscultation. Examination of head and ears normal; nose, mucous membranes inflamed with postnasal phlegm. Diagnosis: Acute sinusitis. Plan: Patient was advised to drink fluids, take aspirin as needed for pain, obtain bed rest, and return if symptoms have not improved in 5 days. What is the MDM level for this patient? What diagnosis code would be reported for this patient?

Low, J01.90

Indicate whether the presenting problem to the severity level in the patient: minimal, self-limited, low, moderate, or high. Fourteen-year-old presents with moderate pain in left thumb after a fall from his skateboard. Diagnosis is a sprain of left thumb. What is the level of the presenting problem and the diagnosis codes? (hint: sprain; external cause; activity)

Low, S63.60A, V00.138A, Y93.51

Documented key components include history, examination, and _________________

Medical decision making

Two of the three elements must be met or exceeded to qualify for a level of _______________.

Medical decision making

Indicate whether the presenting problem to the severity level in the patient: minimal, self-limited, low, moderate, or high. Established patient, 34 years old, presents for a blood pressure check due to her malignant hypertension. What is the level of the presenting problem and the diagnosis code?

Minimal, I10

A new patient's record states that an initial office visit was made for the evaluation and management of a 48-year-old male with recurrent low back pain from a herniated disc, with pain radiating to the leg (myelopathy). A detailed history and a detailed examination were performed. Using this information identify the following factor: Risk if left untreated. (Risk can be minimal, low, moderate, or high.)

Moderate

Locate the subsection office and other outpatient services in the CPT, then the category new patient in the E/M section to answer the following question: What is the patient status?

New

Can time be utilized to determine a consultation level of service rather than the key components, yes or no?

No

What are the times associated with codes 99281-99285?

None

Is the following a body area (BA) or organ system (OS): Ears

OS

Is the following a body area (BA) or organ system (OS): Eyes

OS

Is the following a body area (BA) or organ system (OS): Genitourinary

OS

Is the following a body area (BA) or organ system (OS): Heart

OS

Is the following a body area (BA) or organ system (OS): Lungs

OS

Is the following a body area (BA) or organ system (OS): Lymphatics

OS

Is the following a body area (BA) or organ system (OS): Mouth

OS

Is the following a body area (BA) or organ system (OS): Musculoskeletal

OS

Indicate whether the presenting problem to the severity level in the patient: minimal, self-limited, low, moderate, or high. Physician recommends an over-the-counter medication for patient with seasonal grass allergic reaction. What is the level of the presenting problem and the diagnosis code?

Self-limited, J30.1

Consultation

Service rendered by a physician whose opinion or advice is requested by another physician.

A new patient, an 8-year-old female, is brought into the office by her mother, who states that the child has an earache in the right ear. Mother reports that the child has been complaining of pain in right ear with a severity of 8 out of 10 for the past 2 days. Child appears to be in only minor distress. Temperature, 101 degrees Fahrenheit. Tympanic membranes red, fluid noted in right ear. Health history reviewed. Diagnosis: Acute serous otitis media. What is the MDM level for this patient? What diagnosis code would be reported for this patient?

Straightforward, H65.01

99211: This minimal service level does not exist in New Patient category because a new patient is seen by a physician. The established patient may or may not be seen by the physician. Read the description and information for code 99211 in the CPT manual. Would an established patient returning for a simple blood pressure check be appropriately reported as 99211?

Yes

Could a physician assign 99211 to report a patient encounter, yes or no?

Yes

If a patient presents to the emergency department in a clinically life-threatening state that prevents the physician from performing a complete history or physical examination, could the code 99285 still be reported? Yes or no?

Yes

For CPT code 99205, the history level is _____________, the examination level is __________, and the MDM is of ____________ complexity.

comprehensive, comprehensive, high

For CPT code 99204, the history level is _____________, the examination level is __________, and the MDM is of ____________ complexity.

comprehensive, comprehensive, moderate

For CPT code 99203, the history level is _____________, the examination level is __________, and the MDM is of ____________ complexity.

detailed, detailed, low

Which levels of history require the documentation of the Chief Complaint (CC)? a) Problem focused b) Expanded problem focused c) Detailed d) Comprehensive e) All of the above

e) All of the above

The above categories/subcategories must meet or ______________ ______________ of the three key components.

exceed, three