Coding 2 & 3 Ch. 9 CPT Evaluation and Management

A 75-year-old established patient presents for his annual physical examination. The patient's chronic conditions are well controlled with diet and exercise.

99397

A physician called an established patient to inform her that the results of a chest x-ray were negative. The call was 5 minutes in duration. The patient had previously been seen in the office 10 days ago.

99441

Dr. Killean called a patient to report the results of his blood test that was performed 10 days ago, and he instructed the patient to lower the dosage of his Coumadin and schedule an appointment to be seen in the office 30 days from now. Medical discussion during this telephone service was 10 minutes in duration. Select the proper code. a. 99443 b. 99442 c. 99441 d. 99444

99441

A patient emailed his physician to ask whether taking 500 mg of cinnamon tablets daily would be acceptable, given the prescribed medications he takes. The physician replied, approving his taking 500 mg of cinnamon tablets daily. The patient had previously been seen by the physician in the office 15 days ago, and he is scheduled to receive office E/M services in 60 days as part of his routine care.

99444

A 58-year-old man was seen by his private physician for an examination as part of his claim for long-term medical disability. The patient has chronic obstructive lung disease with severe emphysema and has been unable to work during the past year. The physician documents a comprehensive medical history and a detailed examination. The physician reviews the patient's current medical treatment plan and recommends that it continue. All of the necessary documentation required by the insurance company is completed, including the physician's opinion that the patient would be unable to work in the future, as his pulmonary function is markedly impaired in spite of continual respiratory and pharmacologic therapy.

99455

A patient was seen in the office and underwent a baseline physical for the purpose of obtaining medical disability. Select the proper code. a. 99201 b. 99211 c. 99455 d. 99381

99455

The physician documented the history and exam of a normal, healthy newborn admitted and discharged on the same day. Select the proper code. a. 99463 b. 99431 c. 99221 d. 99499

99463

An infant is admitted to the neonatal intensive care unit (NICU) shortly after birth on Tuesday morning. The infant remains on life support through Thursday. Select the proper code(s). a. 99468, 99469 b. 99468 c. 99468, 99469, 99469 d. 99295, 99296, 99296

99468, 99469, 99469

A 50-year-old female patient was admitted to the hospital on 10/10 with a diagnosis of pneumonia due to Staphylococcus aureus, at which time she received level 2 E/M services from her attending physician. On 10/11 and 10/12, the patient received level 2 E/M services. On 10/13, the patient was discharged from the hospital in improved condition to follow up with the physician at home; the physician spent 30 minutes performing discharge day management functions. (10/10): (10/11): (10/12): (10/13):

(10/10): 99222 (10/11): 99232 (10/12): 99232 (10/13): 99238

A full-term healthy newborn girl received initial and subsequent hospital care services on July 7 and July 8, respectively. (7/8): (7/9):

(7/8): 99460 (7/9): 99462

Physician spent 40 minutes reviewing reports and modifying pain medication and oxygen orders for a 70-year-old hospice patient with terminal lung disease and a do-not-resuscitate order. Select the proper code. a. 99374 b. 99379 c. 99377 d. 99378

99378

A 13-year-old new patient presents for a well-check examination. The patient does not report any medical complaints.

99384

very low birth weight

1500-2500 grams.

A patient returns to the physician's office today with neck and back pain. During a previous office visit last month, the patient was diagnosed as having multiple areas of bulging discs. The patient is not considered a surgical candidate at this time. Significant trauma in the past is noted, but C2-12 are intact. Deep tendon reflexes are within normal limits and symmetrical in the upper and lower extremities. Heart, lungs, and abdomen are without significant pathology. There are marked paravertebral spasms throughout the cervical, thoracic, and lumbar regions. HEENT: Patient has bilateral otitis externa noted. Which code is assigned for this level 4 E/M service? a. 99203 b. 99204 c. 99214 d. 99213

99214

CMS often refers to E/M codes by level numbers, and the level often corresponds to the last digit of the CPT code. Therefore, code 99215 is a level _ service.

5

A 55-year-old female came in with the complaint of severe abdominal pain. The patient was admitted on 05/07 to observation due to the severity and location of her pain. The admitting physician performed a comprehensive history and a detailed examination and documented medical decision making of a moderate complexity given the amount of possible diagnoses, including appendicitis, gastric ulcer, cholelithiasis, and pyelonephritis. Various diagnostic tests were ordered and done, including barium enema, upper gastrointestinal endoscopy, and KUB (kidneys, ureters, bladder) x-ray. No disease or disorder was found, and the patient was discharged from observation on 05/08. The patient reported a decrease in her pain after 30 hours of IV analgesics and antispasmodics. The physician documented that the patient should follow up with her primary care physician in two days or return to the hospital if the pain worsens. The physician also documented a final detailed examination of the patient and dictated a discharge summary report. 5/7: 5/8:

5/7: 99218 5/8: 99217

A 16-year-old outpatient who is a new patient to the office complains of severe facial acne. The history and physical examination are expanded problem focused. The physician must consider related organ systems in addition to the integumentary system in order to treat the condition. With minimal number of diagnoses to consider and the minimal amount of data to review, the physician's decision making is straightforward with regard to the treatment of this patient.

99202

A new patient presents to the physician's office with complaints of severe earache, jaw pain, and facial swelling. The physician obtains a detailed history of the chief complaint, an extended review of systems, and a problem pertinent past/family/social history and performs a detailed exam. Medical decision making is of low complexity. Which E/M code is reported? a. 99214 b. 99204 c. 99205 d. 99203

99203

A 4-year-old female established patient received Evaluation and Management services, which included a problem focused history, an expanded problem focused exam, and medical decision making (MDM) of a low level. The patient is diagnosed with influenza.

99213

An established patient has a four-month office check-up for medical management of high triglyceride levels. A brief history of present illness and a problem pertinent review of systems are obtained. The physician counsels the patient on diet and exercise and advises the patient to return again in four months. Which E/M code is reported? a. 99213 b. 99202 c. 99232 d. 99214

99213

An established patient with a history of asthma presents in an office visit with acute bronchospasm and moderate respiratory distress. The physician conducts a problem focused history followed by a detailed examination, which shows a respiratory rate of 30. Office treatment is initiated: intermittent bronchial dilation and subcutaneous epinephrine. This service requires the physician to have intermittent direct contact with the patient over a two-hour period. The MDM complexity is moderate.

99214, 99354, 99355

Which code reflects a level 5 E/M service? a. 99215 b. 99211 c. 99214 d. 99212

99215

A patient was in an automobile accident and is complaining of a minor headache and no other apparent injuries. History gathered from bystanders states that the 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 then admitted for 24-hour observation to rule out head injury. A comprehensive history and exam are performed by the physician. The MDM is of moderate complexity.

99219

A patient is admitted with head injury. On the initial visit, the physician observes that the patient is unconscious and is bleeding from the right ear. The physician spends 70 minutes treating the patient and coordinating care, during which time a comprehensive history and exam are obtained. Which E/M code is reported? a. 99285 b. 99222 c. 99223 d. 99221

99223

An inpatient follow-up consultation is performed for a 70-year-old Medicare patient who is experiencing foot drop after leg surgery. The foot has regained normal positioning. Which E/M code is reported? a. 99221 b. 99241 c. 99251 d. 99231

99231

A subsequent hospital visit is required for a 58-year-old patient admitted with an esophageal neoplasm who has begun to spit up blood. Metastasis is suspected. Which E/M code is reported? a. 99233 b. 99285 c. 99236 d. 99255

99233

An established patient is seen in the hospital on day two of his hospital stay. The patient had been admitted through the emergency department with status asthmaticus and had been undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a detailed interval history and a detailed physical exam. The possibility of pneumonia complicating the asthma must be considered. The patient's respiratory condition is still unstable. The MDM complexity was high.

99233

A patient with severe chest pain is admitted for observation. A comprehensive history and examination are performed. Medical decision making is moderate. The patient is released the same day. Which E/M code is reported? a. 99219 b. 99222 c. 99202 d. 99235

99235

A 52-year-old patient was sent to a surgeon for an office consultation concerning hemorrhoids. An expanded problem focused history and examination were performed. The consultant recommended treating with medication after a straightforward MDM.

99242

A 38-year-old patient with neck stiffness and pain radiating down the right arm presents to the neurosurgeon for an office consultation. A detailed history and exam are obtained during the 40-minute encounter. Which E/M code is reported? a. 99204 b. 99221 c. 99243 d. 99244

99243

An inpatient is seen for an initial consultation regarding a cardiac procedure. The consulting physician documented a comprehensive history and exam and spent 80 minutes with the patient. Medical decision making was of moderate complexity. Select the proper code. a. 99255 b. 99254 c. 99284 d. 99244

99254

A 13-year-old male was admitted yesterday for a tympanotomy. Postsurgically, the child developed fever and seizures of unknown origin. A pediatric consultation was requested. This was done on the second hospital admission day and 24 hours after surgery. The history of present illness (HPI) was extended with a complete review of systems (ROS). A complete past/family/social history (PFSH) was elicited from the mother as part of a comprehensive history. A comprehensive examination was conducted on all body areas and organ systems. The MDM complexity was high.

99255

A woman is seen in the emergency department for a broken arm she sustained after slipping on ice. A problem-focused history and physical were performed, and medical decision making was straightforward. Select the proper code. a. 99282 b. 99201 c. 99281 d. 99221

99281

A patient was seen in the emergency department after she burned her hand with scalding water. An expanded problem focused history and exam were performed. Medical decision making was of low complexity. Which E/M code is reported? a. 99283 b. 99282 c. 99213 d. 99232

99282

A patient is brought to the emergency department with a stab wound in the upper arm. An expanded problem-focused history and examination are performed, and medical decision making is of moderate complexity. Select the proper code. a. 99202 b. 99283 c. 99213 d. 99232

99283

A patient presents with the complaint of hematemesis. The patient also has a rapid pulse rate and low blood pressure. In the ED, critical care is provided by the ED attending to raise the patient's blood pressure and decrease blood loss. This is done for 70 minutes before the patient is transferred to the surgical suite for an endoscopic procedure to evaluate his esophagus. The ED physician also documents a detailed examination and MDM of high complexity. Due to the patient's medical condition, he is unable to provide any history; no family is present to provide information.

99284-25, 99291

A patient in the emergency department (ED) has a temperature of 103°F and is in acute respiratory distress. Symptoms include shortness of breath, chest pain, and gasping. The physician is unable to obtain a history or perform a comprehensive physical examination because the patient's condition is critical. The MDM complexity is high.

99285

With two-way communication, the physician directs the emergency medical technicians (EMTs) in an ambulance en route to the emergency department with a patient in apparent cardiac arrest.

99288

A physician is called to the intensive care unit to provide care for a patient who received second- and third-degree burns over 50 percent of his body due to a chemical fire. The patient is in respiratory distress and is suffering from severe dehydration. The physician provides support for two hours. Later that day, the physician returns and provides an additional hour of critical care support to the patient.

99291, 99292, 99292, 99292, 99292

A 72-year-old patient suffered a cerebral vascular accident (CVA). Today the patient is admitted to a skilled nursing facility (SNF) for rehab and medical care. The patient was just discharged from an acute care facility. The SNF medical director documents a comprehensive history, including the patient's chief complaint of paralysis and weakness, an extended HPI, and a complete ROS. A detailed exam of the patient's cardiovascular, respiratory, musculoskeletal, neurological, and genitourinary systems is documented. The physician orders a multidisciplinary rehabilitation care plan for the patient and the continued treatment of the patient's other medical conditions, including hypertension and diabetes. The MDM complexity is high.

99304

A physician performs a scheduled follow-up visit to a 65-year-old patient in a nursing facility who is recovering from pneumonia. The patient has responded well to the treatment, and no complications are noted. Which E/M code is reported? a. 99324 b. 99341 c. 99307 d. 99308

99307

Subsequent follow-up care is provided for a comatose patient transferred to a long-term care center from the hospital two days ago. The resident shows no signs of consciousness on examination but appears to have developed a minor upper respiratory tract infection with a fever and rales heard on auscultation. The physician performs an expanded problem focused history and a problem focused interval examination with respiratory status and status of related organ systems such as cardiovascular. The physician is concerned that the respiratory infection could progress to pneumonia and orders the appropriate treatment. The MDM complexity is moderate.

99308

A nursing facility resident began to experience periods of memory loss and disorientation. The physician performed a detailed interval history and exam. The physician spent 30 minutes talking with the patient and documenting in the medical record. Select the proper code. a. 99309 b. 99307 c. 99310 d. 99308

99309

A new patient diagnosed with mild intellectual disabilities and self-abuse is sent to a custodial care facility for admission. The patient's family is no longer able to care for the patient at home. The care facility physician documents a problem focused history with a problem focused exam. The medical decision making documented was straightforward.

99324

A 21-year-old patient with a recent history of drug abuse is admitted to a rehab center for treatment. In the patient's second week of treatment, she complains of back pain and is seen by the same physician who evaluated her medically upon admission. At this time, the physician documents a problem focused interval history, an expanded problem focused examination, and MDM of moderate complexity.

99335

A 15-year-old new patient has cystic fibrosis and is having problems with her Pulmozyme dosage. This medication is used to thin the mucus that clogs her lungs. The patient is having moderate throat pain and slight tightness in her chest. The physician makes a home visit to gather HPI and ROS and pertinent past personal medical information for a detailed history. The detailed exam focuses on the body systems currently affected by the cystic fibrosis and related organ systems: ears, nose, throat, mouth, respiratory, gastrointestinal, and cardiovascular. The MDM complexity is of a moderate level.

99343

10. A home care physician provided E/M home care services to a new 54-year-old male patient who complained of dyspnea due to cirrhosis of the liver and ascites. The home care physician spent 60 minutes reviewing the patient's record, taking a comprehensive history, and performing a comprehensive examination. Medical decision making was of moderate complexity. The home care physician then spent an additional 20 minutes documenting the home visit report and coordinating care with the patient's primary care physician. Assign the appropriate CPT code.

99344

A 64-year-old female patient has diabetes and has been having problems adjusting her insulin doses. She has had an onset of dizziness and sensitivity to light. Her primary care physician, who has treated her for this condition during the past four years, makes a home visit today. At this visit, the physician gathers a brief HPI and a problem pertinent ROS during the problem focused history. The physical exam focuses on the body systems currently affected by the diabetes. The patient's condition is moderately severe and the MDM complexity is of a moderate level.

99348

A patient was in the delivery room ready to give birth. When the physician had the patient start pushing, possible complications for the infant were noted and the hospital pediatric neonatal specialist was notified of a possible need for her evaluation of this newborn. The pediatric specialist was notified at 9:20 am. At 10 am, she was informed via phone call from the OB/GYN that the infant had normal Apgar scores of 9 and 9.

99360

A patient with a heart condition is scheduled to undergo a cesarean section. Due to the high-risk nature of the delivery, the attending physician requests standby service from a cardiac surgeon; and 45 minutes later the patient delivers a healthy newborn with no complications. Select the proper code(s). a. 99360 b. 99360, 99360 c. 99026 d. 99027

99360

A 14-year-old boy twisted his ankle while playing soccer. He received level 3 E/M services from his physician the next morning for which code 99213 was reported on the CMS-1500 claim generated immediately after the visit. The physician ordered an x-ray of the ankle, and the child left the office after the x-ray but did not see the physician. Later that afternoon the patient and his mother came into the office and met with the physician, an orthopedic surgeon, and a rehabilitation therapist. Medical discussion was 45 minutes in duration.

99366

A 72-year-old patient with a history of breast cancer has a suspicious mass in her uterus. A biopsy was done. The determination was that the patient had a carcinoma in situ of the uterus. The physician who conducted the surgery called a face-to-face meeting with his fellow surgeons and discussed the case and the patient's outcome for 30 minutes.

99367

A 75-year-old patient was just diagnosed with type 1 diabetes. This means that the patient will have to give himself insulin shots. The physician supervised the coordination of home health care, which required 30 minutes of his time.

99375

A 50-year-old female has brain cancer, and the physician supervised the coordination of hospice services, which required 45 minutes of his time.

99378

A six-year-old child is seen by her family physician for her annual check-up and immunizations. Her last encounter was one year ago. Which E/M code is reported? a. 99393 b. 99383 c. 99251 d. 99211

99393

Time is a contributing factor in E/M code selection for which scenario? a. Dr. Knolles spent 10 minutes reviewing information on drugs to find one that the patient could tolerate. b. Dr. Bender showed frightened little Jimmy the x-ray of his broken arm and explained why a cast would help him get better. c. After Dr. Harris diagnosed Ellen with an ear infection, he explained the prognosis and wrote a prescription for an antibiotic. d. A patient had an encounter solely for the purpose of discussing treatment options for a recently diagnosed condition.

A patient had an encounter solely for the purpose of discussing treatment options for a recently diagnosed condition.

Which is reported using a non-face-to-face service code? a. A patient involved in a motor vehicle accident came to the emergency department with complaints of a sore neck and blurry vision. The patient was diagnosed with whiplash. The attending physician requested an ophthalmology consultation during the encounter, but no physicians were available so he scheduled the consultation for the following day. He instructed the patient to follow up with her primary care physician if symptoms persisted. b. A physician called the patient at home to discuss the results of her lab tests. After reviewing the reports, he believed that further testing was necessary and advised her to make an appointment as soon as possible. c. A patient came into the emergency department with severe pain in the lower back. She told the physician that she had recently had an MRI at that facility but hadn't received the results yet. The physician looked up the test results and verified that a displaced disc was causing the pain. d. During an encounter, a physician recommended physical therapy to a patient with rheumatoid arthritis. She expressed concern over which facility she should contact and how she would get there. Before she left, the physician provided her with names and numbers of facilities she could contact for treatment, as well as agencies that would assist in her transportation needs.

A physician called the patient at home to discuss the results of her lab tests. After reviewing the reports, he believed that further testing was necessary and advised her to make an appointment as soon as possible.

Clinical examples of E/M codes are found in _________ of the CPT coding manual. a. Appendix A b. Appendix D c. Appendix B d. Appendix C

Appendix C

Outpatient--Emergency Department (Gastroenterology) Patient Name: Marcia Cleary Diagnoses: Probable diverticulitis A 49-year-old female walked into the emergency department (ED) accompanied by a friend. She complained of severe abdominal pain with localized tenderness in the left lower quadrant and feeling feverish. Her history included a change in bowel function to constipation interrupted by periods of diarrhea. The ED physician performed a Level 3 E/M service, and upon examination a palpable mass was palpated in the left lower quadrant. The blood test showed leukocytosis. The ED physician ordered pain medication and antibiotics. He explained to the patient that she had a probable diagnosis of diverticulitis, but she needed to be referred to a surgical consult for further evaluation to confirm the diagnosis and to rule out colon carcinoma. CPT: ICD-10-CM:

CPT: 99283 ICD-10-CM: R19.04, D72.829, R19.4, R50.9

A physician spent approximately two hours on a conference call coordinating activities with members of a transplant team who were preparing to perform an organ transplant on his patient. From which E/M subsection would the code for this service be reported? a. Critical Care Services b. Care Plan Oversight Services c. Case Management Services d. Special Evaluation and Management Services

Case Management Services

Dr. Benjamin practiced at Hopewell Medical Center until 2002, when he began to practice with Dr. Evans at the Lakewood Clinic. Which would be considered a new patient at Lakewood Clinic? a. Debra injured her back two years ago and has been under continuous treatment at another facility. She had her records transferred to Lakewood Clinic and is going to be seen by Dr. Evans for continuing treatment of her chronic condition. b. Martha had a physical performed on June 1, 2003, by Dr. Benjamin and is seen by Dr. Evans on September 30, 2005, for a sinus condition. c. Sheryl was treated last month by Dr. Evans. This week she needs to be seen again, but Lakewood Clinic is closed for the holiday. She is seen by an on-call physician who is covering for Dr. Evans. d. Henrique, who had last seen Dr. Benjamin at Hopewell Medical Center in April 2001, is treated by Dr. Benjamin at the Lakewood Clinic in March 2004.

Debra injured her back two years ago and has been under continuous treatment at another facility. She had her records transferred to Lakewood Clinic and is going to be seen by Dr. Evans for continuing treatment of her chronic condition.

For a 24-year-old male patient who received immediate care in the hospital emergency room, the coder should refer to the E/M category entitled ________ Department Services.

Emergency

When a physician provides emergency services to a patient in the office, a code from the Emergency Department Services category of E/M should be reported. a. True b. False

False

Problem focused, expanded problem focused, detailed, and comprehensive are terms used to describe which components of an E/M level of service code? a. Extent of history and extent of exam b. Extent of history c. Review of systems d. Extent of exam

Extent of history and extent of exam

A neonate is a newborn, up to one year old. a. True b. False

False

Code 99211 is commonly thought of as a "nurse visit" because it can be reported only when a nurse provides office E/M services for an established patient. a. True b. False

False

Codes for prolonged services are reported instead of other physician services, such as hospital inpatient services. a. True b. False

False

During special evaluation and management services, the examining provider assumes active management of the patient's health problems. a. True b. False

False

Initial inpatient consultation codes are reported when consultation services are provided to acute care hospital inpatients only. a. True b. False

False

Initial observation care codes are reported for patients who are admitted and discharged from observation services on the same date. a. True b. False

False

Medical services are usually provided to residents of an assisted living facility by the facility's staff. a. True b. False

False

Newborn care code 99460 is reported for birthing center care only. a. True b. False

False

Preventive medicine services are reported when a patient who is receiving treatment for a specific disorder returns to the office for a "recheck of a known problem." a. True b. False

False

Teaching physicians are required to rewrite in entirety the key elements of a resident physician's E/M documentation. a. True b. False

False

When a physician provides more than one Evaluation and Management (E/M) service for the same patient on the same day and the patient's problem is the same for each encounter, report an E/M service code for each encounter. a. True b. False

False

When a physician provides two E/M office or other outpatient services to the same patient on the same day and the patient's problems are different for each E/M service, report multiple E/M codes and attach modifier -51 to the second code. a. True b. False

False

When the provider performs a comprehensive exam in the office and the patient is later admitted to the hospital on another day, void the previously submitted claim on which the office E/M code was reported and report a higher level of service initial hospital care E/M code for the hospital admission. a. True b. False

False

There are seven components to a level of E/M service code description. Which are considered key components when selecting the E/M code? a. Counseling, coordination of care, and nature of presenting problem b. History, exam, and time c. History, exam, and medical decision making d. Medical decision making, time, and nature of presenting problem

History, exam, and medical decision making

A patient was admitted to the hospital on November 4 for reconstructive surgery. After surgery, the physician reviewed the patient's record to determine how the patient was responding to the treatment. The patient was discharged November 6. Under which subsection of Hospital Inpatient Services would the code for the November 6 encounter be located? a. Initial Hospital Care b. Observation or Inpatient Care Services c. Hospital Discharge Services d. Subsequent Hospital Care

Hospital Discharge Services

Which contributory component would be considered when determining the number of diagnoses or management options for medical decision-making complexity? a. Nature of the presenting problem b. Time c. Coordination of care d. Counseling

Nature of the presenting problem

Mary Smith was seen in her primary care provider's office two months ago when she underwent a routine physical examination. She returns today with complaints of severe abdominal pain and discomfort. Diagnostic testing revealed Crohn's disease, and a treatment plan was discussed. Identify each of the following for services provided to Mary Smith today. E/M Category: ______ or Other Outpatient Services

Office

chief complaint (CC)

patient's description of medical condition stated in the patient's own words.

When a 49-year-old female patient is seen in the provider's office for an annual physical examination, the coder should refer to the E/M category entitled __________ Medicine Services.

Preventive

A patient experiencing acute breathing trouble required one hour of direct face-to-face care from the physician. In addition to the appropriate level of E/M service code, which E/M subsection should be referenced to assign an additional code? a. Care Plan Oversight Services b. Case Management Services c. Preventive Medicine Services d. Prolonged Services

Prolonged Services

A hospital discharge day management code is reported with a subsequent hospital care services code on the same date. a. True b. False

True

A patient who is referred by a physician for hospital observation services, bypassing the outpatient or emergency department, is considered a "direct admission to observation." a. True b. False

True

Care plan oversight services codes are classified separately from other E/M codes when the physician is involved in direct patient examinations. a. True b. False

True

Case management services include team conferences. a. True b. False

True

Critical care services require personal management by the physician. a. True b. False

True

Do not report a subsequent nursing facility service code and an initial hospital care service code on the same date for the same patient. a. True b. False

True

Documentation of all face-to-face E/M home services visits and any telephone communications with the patient or caretakers must be documented in the patient's record. a. True b. False

True

For a code from the Office or Other Outpatient Consultations category to be reported, the consultation request must be initiated by the attending physician or another health care provider and the attending physician must document all consultation requests in the patient's record. a. True b. False

True

Observation services are provided in a hospital outpatient setting, and the patient is considered an outpatient. a. True b. False

True

Reporting emergency department (ED) services codes is not restricted to ED physicians employed by the hospital. a. True b. False

True

Subsequent hospital care includes the review of the patient's record for changes in the patient's condition, the results of diagnostic studies, and/or the reassessment of the patient's condition since the last assessment performed by the physician. a. True b. False

True

The provider does not have to redocument the history, review of symptoms, and past/ family/social history documented during a previous encounter if the provider documents that the previous information was reviewed and then updates the information. a. True b. False

True

When a patient is admitted as a hospital inpatient after receiving observation services on the same date, report only an initial hospital care code. a. True b. False

True

When a physician who provides standby services performs surgery, the standby services are included in the surgical procedure's global period. a. True b. False

True

When the patient receives office or other outpatient E/M services and is admitted to the hospital as an inpatient by the same physician, report an E/M code for the initial hospital care only. a. True b. False

True

extent of history

categorized according to problem focused history, expanded problem focused history, detailed history, or comprehensive history.

intraservice time

a variable that is predictive of the "work" of E/M services, which includes face-to-face time for office and other outpatient visits or unit/floor time for hospital and other inpatient visits.

1. Refer to the Evaluation and Management section of CPT and identify a code for each level of service listed. a. Office or other outpatient visit, new patient, level 4: b. Office or other outpatient visit, established patient, level 1: c. Hospital inpatient services, initial hospital care, level 2: d. Home visit, new patient, level 5: e. Emergency department services, level 3:

a. 99204 b. 99211 c. 99222 d. 99345 e 99283

8. Dr. Kuhl performed a level 3 E/M service to treat an 18-year-old established female patient in the office for a urinary tract infection. Urine culture revealed Escherichia coli bacteria. The patient was prescribed antibiotics and instructed to return for recheck in 10 days. a. The CPT E/M category and subcategory is Office or Other Outpatient Services, ___________ Patient. b. The appropriate CPT code is:

a. Established b. 99213

9. Review the case below and answer the questions to assign the E/M office or other outpatient code. (You will have to identify the elements documented in the case to determine the level of history, level of examination, and complexity of medical decision making.) SUBJECTIVE: A 54-year-old female patient is seen in the office for routine three-month follow-up for evaluation and management of type 2 diabetes mellitus and hypertension. The patient has no new complaints today; she denies chest pain, headache, numbness of the extremities, shortness of breath, or visual changes. The patient states that she has remained on the diet recommended during the last E/M visit and that she is regularly exercising. Home monitoring of blood pressure and glucose levels are within normal limits. OBJECTIVE: Blood pressure 130/78. Weight 145. Pulse 78, regular. HEAD, EYES, EARS, NOSE, THROAT: Pupils equal, round, and reactive to light and accommodation. External auditory canals and tympanic membranes negative. Oropharynx benign. NECK: Supple. No bruits, jugular venous distention, or thyromegaly. CHEST: Breath sounds clear to auscultation and percussion. No rubs, rales, rhonchi, or wheezing. HEART: No click, gallop, irregularity, murmur, or rub. EXTREMITIES: Distal pulses intact. No cyanosis, clubbing, or edema. NEUROLOGICAL: Deep tendon reflexes within normal limits and symmetrical. No decreased lower extremity sensation noted. LAB RESULTS: Fasting blood sugar 132. Urinalysis within normal limits. ASSESSMENT: Type 2 diabetes mellitus, controlled. Benign hypertension. PLAN: Glucotrol 5 milligrams daily, every morning. Procardia XL 30 milligrams daily. Relafen 1,000 milligrams daily. Continue home glucose monitoring. SMA-7 and glycosylated hemoglobin today. Return for routine follow-up in three months. a. Is this patient new or established? b. What is the extent of history? c. What is the extent of examination? d. What is the complexity of medical decision making? complexity e. Which E/M code is assigned?

a. Established b. Expanded Problem Focused c. ? d. Moderate e. 99214

2. An 89-year-old diabetic female presented to the hospital emergency room for evaluation of a very painful lower left arm. An x-ray revealed a left ulnar fracture. After taking a detailed history and performing a detailed exam, the physician reduced the fracture and applied a short-arm cast. Medical decision making was of moderate complexity. A CPT Surgery code was reported on the claim. a. Should an E/M code also be reported for this case? (Yes or No) b. If so, which code?

a. Yes b. ?

3. A 14-year-old male presented to his primary care provider's office for treatment of 3-cm laceration, which the physician sutured. The physician also administered a tetanus toxoid after confirming that the patient's tetanus immunization status was not up-to-date. Codes for treatment of the laceration and administration of the tetanus toxoid were assigned from the CPT Surgery and Medicine sections, respectively. a. Should an E/M code also be reported for this case? (Yes or No) b. If so, which code?

a. no b. ?

social history

age-appropriate review of past and current activities such as daily routine, dietary habits, exercise routine, marital status, occupation, sleeping patterns, smoking, use of alcohol and other drugs, and sexual activities.

face-to-face time

amount of time the office or outpatient care provider spends with the patient and/or family.

unit/floor time

amount of time the provider spends at the patient's bedside and at management of the patient's care on the unit or floor.

The E/M level of service reflects the: a. physical location where health care is provided to a patient. b. amount of work involved in providing health care to a patient. c. type of condition for which the patient is being treated. d. kind of health care services provided to a patient.

amount of work involved in providing health care to a patient.

counseling

as related to CPT E/M coding, a discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and recommended diagnostic studies; prognosis; fisks and benefits of management (treatment) options; instructions for management (treatment) and follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.

physical examination

assessment of the patient's organ and body systems.

extent of examination

categorized according to problem focused examination, expanded problem focused examination, detailed examination, and comprehensive examination.

expanded problem focused history

chief complaint, brief history of present illness, and problem pertinent system review.

comprehensive history

chief complaint, extended history of present illness, review of systems directly related to the problem(s) identified in the history of present illness in addition to a review of all additional body systems, and complete past/family/social history.

history of present illness (HPI)

chronological description of patient's present condition from time of onset to present.

coordination of care

component in which physician makes arrangements with other providers or agencies for services to be provided to a patient.

problem focused history

consists of chief complaint and brief history of present illness or problem.

clinical examples

contained in Appendix C of the CPT coding manual; assist providers in selecting the appropriate code for documented E/M services.

A physician discussed the results of diagnostic testing with his patient. This portion of the encounter is considered: a. coordination of care. b. history of present illness. c. examination. d. counseling

counseling

care plan oversight services

cover the physician's time supervising a complex and multidisciplinary care treatment program for a specific patient who is under the care of a home health agency, hospice, or nursing facility.

critical care

delivery of medical care services to critically ill or injured patients who require the full, exclusive attention of the physician.

nature of the presenting problem

disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.

Dr. Peterson, Dr. Slatterly, and Dr. Vaughan are members of the Medex Pediatric Group Practice. Eric Webb is a 15-year-old boy who was initially seen by Dr. Vaughan on August 5 of last year for a sports physical. Eric returned to the office on September 10 of this year and was seen by Dr. Peterson for treatment of an ear infection. Eric is considered a(n) ___________ (new or established) patient for Dr. Peterson's practice.

established

Mary Smith was seen in her primary care provider's office two months ago when she underwent a routine physical examination. She returns today with complaints of severe abdominal pain and discomfort. Diagnostic testing revealed Crohn's disease, and a treatment plan was discussed. Identify each of the following for services provided to Mary Smith today. E/M Subcategory: ___________ patient

established

Tim Turner was seen by Dr. Chambers on February 5 of this year for follow-up of his type 2 diabetes mellitus. Tim has been Dr. Chambers' patient since 1984, when he was seen for an initial visit. Tim returned to the office each year since 1984 for an annual physical examination until last year, when he was diagnosed with type 2 diabetes mellitus. Since then, Tim has returned for a recheck office visit with Dr. Chambers every three months. Tim is considered a(n) ___________ (new or established) patient for Dr. Chambers' practice.

established

Codes for E/M levels of service reflect the amount of work involved in providing health care to a patient, and correct coding primarily involves determining the extent of history and ___________ performed and the complexity of medical decision making.

examination

consultation

examination of a patient by a health care provider, usually a specialist, for the purpose of advising the referring or attending physician in the evaluation and/or management of a specific problem with a known diagnosis.

Documentation Guidelines for Evaluation and Management Services

explain how E/M codes are assigned according to elements associated with comprehensive multisystem and single-system examinations.

detailed examination

extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Documentation of the review of systems is used to establish: a. presence of contributing factors. b. complexity of medical decision making. c. extent of history obtained. d. extent of examination performed.

extent of history obtained.

advance care planning

face-to-face services between physician or other qualified health care professional and patient, family member, or surrogate for the purpose of counseling and discussing advance directives, with or without completing relevant legal forms (e.g., health care proxy).

professional services

face-to-face services provided by a physician or nonphysician practitioner (e.g., nurse practitioner, physician assistant) and reported by assigning an E/M code.

Sandy Tyler was admitted to the hospital on July 4 for treatment of a fractured pelvis, which he sustained while parasailing earlier in the day. On July 5, his attending physician (an orthopedic surgeon) wrote a physician's order requesting a neurologist to consult with the patient regarding numbness of his left foot. The orthopedic surgeon reports the diagnosis of ________ pelvis to justify inpatient E/M services.

fractured

comprehensive examination

general multisystem examination or complete examination of a single organ system.

key components

history, examination, and medical decision making; required when selecting an E/M level of service code.

contributory components

include counseling, coordination of care, nature of presenting problem, and time; they are used to select the appropriate E/M service code when patient record documentation indicates that they were the focus of the visit.

preventive medicine services

include routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical.

detailed history

includes chief complaint, extended history of present illness, problem pertinent system review extended to include a limited number of additional systems, and pertinent past/family/social history directly related to patient's problem.

newborn care services

includes services provided to newborns in a variety of health care settings.

hospital discharge service

includes the final examination of the patient; discussion of the hospital stay with the patient and/or caregiver; instructions for continuing care provided to the patient and/or caregiver; and preparation of discharge records, prescriptions, and referral forms.

pediatric critical care patient transport

includes the physical attendance and direct face-to-face care provided by a physician during the interfacility transport of a critically ill or critically injured patient aged 24 months or younger.

history

interview of the patient that includes the following elements: history of the present illness (including the patient's chief complaint), a review of systems, and a past/family/social history.

review of systems (ROS)

inventory by systems to document subjective symptoms stated by the patient; also provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant.

system review

inventory by systems to document subjective symptoms stated by the patient; also provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant.

low birth weight

less than 1500 grams.

expanded problem focused examination

limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

problem focused examination

limited examination of the affected body area or organ system.

The three key components that determine an E/M code include extent of history, extent of examination, and complexity of medical decision ______.

making

Kristin Broome was seen by Dr. Marlot on March 8 six years ago for treatment of influenza. She returned on January 5 one year later for her annual physical examination, which included a prescription for birth control pills. Kristin called the office on April 10 of that same year to request that the local pharmacy be called so she could receive a refill of her birth control pills. Dr. Marlot called in the prescription that afternoon. Kristin next returned to the office on April 15 of this year for an annual physical examination. Kristin is considered a(n) ___ (new or established) patient for Dr. Marlot's practice.

new

neonate

newborn, up to 28 days old.

Sandy Tyler was admitted to the hospital on July 4 for treatment of a fractured pelvis, which he sustained while parasailing earlier in the day. On July 5, his attending physician (an orthopedic surgeon) wrote a physician's order requesting a neurologist to consult with the patient regarding numbness of his left foot. The neurologist reports the diagnosis of ________, left foot, to justify inpatient E/M consultation services.

numbness

transfer of care

occurs when a provider who is managing some or all of a patient's problems relinquishes that responsibility to another provider who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services; the provider transferring care no longer manages these problems but may continue to manage other conditions.

preoperative clearance

occurs when a surgeon requests that a specialist or another physician examine a patient and indicate whether the patient can withstand the expected risks of a specific surgery.

Mary Smith was seen in her primary care provider's office two months ago when she underwent a routine physical examination. She returns today with complaints of severe abdominal pain and discomfort. Diagnostic testing revealed Crohn's disease, and a treatment plan was discussed. Identify each of the following for services provided to Mary Smith today. Place of Service: physician's ______

office

Mary Smith was seen in her primary care provider's office two months ago when she underwent a routine physical examination. She returns today with complaints of severe abdominal pain and discomfort. Diagnostic testing revealed Crohn's disease, and a treatment plan was discussed. Identify each of the following for services provided to Mary Smith today. Type of Service: ______ visit

office

critical illness or injury

one that acutely impairs one or more vital organ systems, jeopardizing the patient's survival.

new patient

one who has not received any professional services within the past three years from the physician or from another physician of the same exact specialty or subspecialty who belongs to the same group practice.

established patient

one who has received professional services within the past three years from the physician or from another physician of the same exact specialty or subspecialty who belongs to the same group practice.

intensivist

physician who has received extensive training and experience in critical care and who specializes in the care of critically ill patients, usually in an intensive care unit (ICU).

standby service

physician, or other qualified health care professional, spending a prolonged period of time without patient contact waiting for an event to occur that will require the physician's or professional's service.

prolonged services

physicians' services involving patient contact that are considered beyond the usual service in either an inpatient or an outpatient setting.

The physical location where health care is provided to patients is called the _____ of service.

place

Which is considered a consultation and occurs when a surgeon requests that a specialist or another physician examine a patient and indicate whether the patient can withstand the expected risks of a specific surgery? a. preoperative clearance b. special evaluation and management services c. physician standby services d. confirmatory consultation

preoperative clearance

A patient presented with a bruised and swollen finger and was in extreme pain. The patient told the physician that she was loading groceries in her car when her son leaned on the door, causing it to slam shut on her finger. An x-ray was obtained, and the broken finger was put in a splint. After asking about any known allergies, the physician wrote a prescription for the pain and advised the patient to return if symptoms persisted beyond a week. Which type of history was performed? a. detailed b. comprehensive c. expanded problem focused d. problem focused

problem focused

physician case management

process in which a physician is responsible for direct care of a patient and for the coordination and control of access to or initiation and/or supervision of other health care services needed by the patient.

special evaluation and management services

provided for establishment of baseline information prior to life or disability insurance certificates being issued and for examination of a patient with a work-related or medical disability problem.

observation service

provided in a hospital outpatient setting; the patient is considered an outpatient.

emergency department service

provided in a hospital, and open 24 hours a day for the purpose of providing unscheduled episodic services to patients who require immediate medical attention.

office or other outpatient services

provided in a physician's office, a hospital outpatient department, or another ambulatory care facility.

inpatient neonatal and pediatric critical care and intensive service

provided to critically ill neonates and infants by a physician.

hospital inpatient service

provided to hospital inpatients, including partial hospitalization services, and indicated when the patient's condition requires services and/or procedures that cannot be performed in any other place of service without putting the patient at risk.

home services

provided to individuals and families in their place of residence to promote, maintain, or restore health and/or to minimize the effects of disability and illness, including terminal illness.

concurrent care

provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day.

referral

recommendation to transfer a patient's care from one provider to another.

medical decision making (MDM)

refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the number of diagnoses or management options, the amount and/or complexity of data to be reviewed, and the risk of complications and/or morbidity or mortality.

type of service (TOS)

refers to the kind of health care services provided to patients, including critical care, consultation, initial hospital care, subsequent hospital care, and confirmatory consultation.

family history

review of medical events in the patient's family, including diseases that may be hereditary or that may present a risk to the patient.

delivery/birthing room attendance and resuscitation services

services provided for attendance at delivery, initial stabilization of the newborn, and delivery/birthing room resuscitation.

partial hospitalization

short-term, intensive treatment program in which individuals who are experiencing an acute episode of an illness can receive medically supervised treatment during a significant number of daytime or nighttime hours.

Which terms describe the levels of work involved in medical decision making? a. face-to-face, unit-floor, pre-encounter, post-encounter b. problem focused, expanded problem focused, detailed, comprehensive c. minimal, self-limited, low severity, moderate severity, high severity d. straightforward, low complexity, moderate complexity, high complexity

straightforward, low complexity, moderate complexity, high complexity

past medical history

summary of past illnesses, operations, injuries, treatments, and known allergies.

When an unlisted procedure or service code is reported, a special report must accompany the claim to describe _________ of the procedure or service. a. whether the patient is new or established b. the nature, extent, and need c. the place of service and type of service d. the type of service and amount of time required

the nature, extent, and need

place of service (POS)

the physical location where health care is provided to patients.

Concurrent care is the provision of similar services to: a. different patients by the same provider on the same day. b. the same patient by the same provider on the same day. c. the same patient by the same provider on different days. d. the same patient by more than one provider on the same day.

the same patient by more than one provider on the same day.

When assigning an E/M code for a new patient, the number of key components that must be considered is two out of _____.

three

Name the contributory components that are considered when determining an E/M code; they are not considered key components: counseling, coordination of care, nature of presenting problem, and ____.

time

interfacility transport

transfer of a patient from one health care facility to another; usually involves use of an ambulance or a helicopter.

When an E/M code is assigned for an established patient, the number of key components that must be considered is __ out of _____.

two; three

The kind of health care services provided to patients is called the ____ of service.

type

infant

very young child, up to one year old.