OST-249 - Chapter 12 - Evaluation and Management
Patient referred here by PCP for foot fracture treatment. Patient stepped on something and has had pain and swelling since. X-ray performed at PCP indicates fracture fifth metatarsal. Reduction performed and patient told to return in 2 weeks for reevaluation. Expanded problem-focused history and exam and low MDM are performed.
28470 only (Patient arrived with dx of fracture fifth metatarsal for treatment. Therefore, only reduction would be coded.)
Patient is being managed for her home INR therapy, review and interpretation of test results, patient instructions, and scheduling additional tests.
93793 (Management of INR therapy is assigned code 93793.)
Patient presents to clinic, status post arthroscopy of left knee 7 days ago with complaints of postop pain and swelling of knee that started approximately 2-3 days ago. Problem-focused history and exam and straightforward MDM were performed.
99024 (Normal, postoperative follow-up care assigned 99024.) WRONG
An established patient is seen in the office for suture removal from a laceration repaired by the same physician 7 days ago. Patient is seen by physician's nurse only and sutures are removed without difficulty.
99024 (While no E/M level is assigned, 99024 for postoperative follow-up visit is assigned to track the encounter. Surgical follow-up period for ALL surgical procedures is 10 days minimum.) WRONG
New patient presents for consultation with ENT physician. After determining the patient is self-referred, the physician performs a problem-focused history and exam, and MDM is low.
99201 (Visit is limited by problem-focused history and exam. Assign 99201 only. Does not qualify for consultation as patient was self-referred.)
A 58-year-old female returns to practice for first time in 4 years with abdominal pain, primarily mid-abdominal. Symptoms present for approximately 2 weeks. Patient reports nausea, vomiting, and diarrhea. No chest pain, SOB, rectal bleeding. Patient has been treated prior to this date for arthritis and hypertension. VS normal. Heart unremarkable, chest clear. Abdomen, soft, tender. Lab shows Hct 43, WBC 7100. Acute abdominal pain, cannot rule out appendicitis. Set up for abdominal ultrasound 10:00 AM tomorrow morning.
99202 (Because the patient has not been seen in the practice in the past 4 years, the visit would qualify for a new patient visit. Hx - Expanded Problem Focused - 99202 Exam - Expanded Problem Focused - 99202 Medical Decision Making - Moderate - 99204 Therefore, since all three elements must be met, would qualify as 99202 only.)
New patient is referred to an ophthalmologist for evaluation of chronic conjunctivitis. An expanded problem-focused history is performed, exam is expanded problem focused, and MDM is low. The ophthalmologist calls the referring physician discussing possible treatment options and the patient will return to her primary care for further treatment.
99202 (History and exam are expanded problem focused (99202), MDM is low (99203). All three elements must be met, therefore, assign 99202. In order to qualify for a consultation, a written referral and request as well as a written report must be completed. Since these were not mentioned, it would be assigned an office visit instead.) WRONG
When patient presents for a scheduled procedure, what service(s) should be coded?
Procedure Only (Only the procedure should be assigned unless the patient has another complaint.) WRONG
Typically, what components determine an evaluation and management service?
history, exam, and MDM (The three components required for E/M services are history, exam, and MDM.)
Patient is seen 3 days postoperatively for a fever and muscle pain unrelated to the surgical procedure. Assign the appropriate E/M modifier, if any, for this service.
modifier -24 (Modifier -24 would be assigned for unrelated E/M during global postoperative period.)
What modifier is appended when the E/M is performed during the global, postoperative period but is unrelated?
-24 (Modifier -24 is assigned for an "unrelated E/Ms" when performed during postoperative global period.)
What modifier is utilized to indicate an E/M is a "significantly, separately identifiable service"?
-25 (Modifier -25 is assigned when an E/M is "significant, separately identifiable.")
Patient presents for shoulder pain. After history, exam, and MDM, diagnostic x-ray as well as lab to rule out arthritis and Lyme disease is performed, her shoulder was injected with 10 ml of 1% lidocaine, 40 mg Kenalog into the acromioclavicular joint. She will return for reevaluation in 2-4 weeks. What modifier(s), if any, would be appropriate?
-25 on E/M service (Modifier -25 should be appended to the E/M service to indicate a "significantly, separately deniable E/M.") WRONG
New patient outpatient visit, detailed Hx, expanded problem-focused exam, MDM moderate.
99202 (Hx - Detailed - 99203 Exam - Expanded Problem Focused - 99202 Medical Decision-Making - Moderate - 99204 All three elements are required; therefore, the encounter would be assigned 99202.
A new patient presents for evaluation of coronary artery disease and asthma. Hx extended into the affected systems and other related systems. Past medical, family, and social history are taken. Exam is detailed. MDM is considered high. What E/M level would be assigned in this instance?
99203 (A detailed history of the illness/injury is documented, therefore, would qualify for detailed Hx. A detailed exam is documented; therefore, the exam qualifies for detailed as well. Medical decision-making was documented as high, which qualifies for high. History - Detailed - 99203 Exam - Detailed - 99203 Medical Decision-Making - High - 99205 Since all three elements must be met, the encounter qualifies for 99203 only.)
Patient seeks second opinion for possible hysterectomy. New patient presents to office where a detailed history and exam are performed and moderate MDM.
99203 (Because the visit is considered a new patient visit, only 99203 or 99204 would be considered appropriate. All three elements must be met, therefore, since the hx/exam were limited to detailed, the visit would be limited to 99203.)
Patient presents for second opinion for his hypertension uncontrolled at this time. A comprehensive history and exam are performed and an EKG and new medications are prescribed. What E/M would be assigned for this service?
99204 (Visit is limited by medical decision-making to 99204 because the presenting problem is not a high threat to life or physiological function. It does not qualify for consultation as the components needed are not documented, namely, an order, referral, and written report back to the requesting provider.) WRONG
Patient arrives for office visit for the first time in 4 years; has been out of the country until recently. A comprehensive reevaluation, comprehensive exam, and high MDM are performed.
99205 (Per CPT a new patient is any patient who has not seen provider in same group in same specialty in 3 years. Therefore, qualifies for new patient. Hx, exam, and MDM qualify for 99205.)
Diabetic patient was seen for his diabetic foot ulcer. His PCP indicates he needs surgical intervention. The patient gets a second opinion from a vascular surgeon who performed a comprehensive history and exam and high MDM. What service would be reported for the vascular surgeon?
99205 (Second opinion does not constitute the conditions required for a consultation, therefore, new patient office visit would be assigned. Comprehensive Hx/exam and high MDM equals 99205. In order to qualify for a consultation, CPT indicates there needs to be a request for an expert opinion from a health care professional and a written order and response.) WRONG
Patient arrives for a blood pressure check only by the nurse with a physician order on file.
99211 (Evaluation and management services that do not require the presence of the physician are assigned 99211.)
Office visit for dressing change to leg performed by physician's nurse. Patient seen previously for wound, result of fall from bike.
99211 (Office visits may be performed by the nurse if the provider of record is in the office and supervising the services. Nurse visits are typically assigned 99211 as there is usually minimal history and exam performed. These visits are usually to perform "re-checks" or nursing duties such as bandage/dressing changes, injections, etc.)
A 70-year-old presents to the OB/GYN office for recheck of previously placed pessary placement by nurse.
99211 (Office visits that do not require the presence of the physician are assigned 99211.)
A 22-year-old male at work caught foot on top step and fell, bruising the outer aspect of his right foot. X-rays are negative. Impression: contusion foot, OTC pain meds as needed.
99212 (Because the history and exam focused only on the foot injury, they would be considered problem focused. As a result, the level could be assigned only a 99212 as defined by CPT guidelines. The encounter does not qualify as a consultation, therefore, codes 99242 and 99241 would not be appropriate.) WRONG
Office visit, established patient, problem-focused history, problem-focused exam, moderate MDM
99212 (History and exam are problem focused; therefore, visit limited to 99212.) WRONG
A 4-year-old presents to his pediatrician with fever, and pulling on the left ear. A problem-focused history and problem pertinent review of systems was performed. A problem-focused exam was performed, and MDM as moderate as a prescription was given for left otitis media. What E/M would be reported?
99212 (Hx and Exam were considered problem focused only. Since two of the three elements (hx, exam, and medical decision making) qualify for problem focused, the visit would be assigned 99212.)
A 21-year-old patient seen in follow-up for otitis media after 10 days of antibiotic treatment. No complaints. ENT clear. Resolved otitis media.
99212 (Hx: Problem focused (problem only) Exam: Problem focused (problem only) MDM: Straightforward Therefore, the visit for an established patient with problem-focused hx/exam would be assigned 99212.)
Established patient seen for earache. History and exam are problem focused and MDM is low. Diagnosis of otitis media, right is made.
99212 (Hx: problem focused, exam: problem focused, two of three needed, therefore, 99212.) WRONG
Office visit for an established patient. Problem-focused history and exam, straightforward MDM.
99212 (Problem-focused history and exam would only qualify for 99212.)
Patient returns after MRI knee performed. MRI was within normal limits, no meniscus tear was shown. Diagnosis is severe contusion of the inferior pole of the patella. In view of this, she will immobilize her knee and arranged for physical therapy for her. Problem-focused history and low MDM were performed.
99212 (Problem-focused history qualifies for 99212, MDM qualifies for 99213. As exam element not documented, assume least significant which is 99212. Therefore, two of the three elements qualify for 99212.) WRONG
Patient returns for evaluation of right groin lesion. He has been previously evaluated for this lesion, however, feels it may have increased in size. Examination shows what appears to be a lipoma in the right groin area. Reassured patient and counseled him regarding the need to monitor size and contact us if he feels it is increasing further in size.
99212 (The encounter would be considered problem focused because the history and exam focused only on the lesion (skin). Therefore, the history and exam would be considered problem focused only.)
Patient returns to clinic today. She has been doing ice treatments for her knee injury and taking ibuprofen as needed. Knee has improved significantly. No swelling, no tenderness. Will continue conservative measures as needed.
99212 (The patient has not undergone a surgical procedure; therefore, neither 99024, postoperative visit, nor E/M would be appropriate answers. Since the history/exam focused on only the area of complaint, it would be considered problem focused. Therefore, code 99212 would be appropriate.)
Patient presents today to discuss her upcoming surgery with her PCP. On assessing her social situation, she is suffering significant knee pain, especially on walking small distances and getting up and down, and would benefit greatly from the knee replacement surgery scheduled for next week by her orthopedic surgeon.
99212 (Would qualify for problem-focused history and exam. Therefore, qualifies for 99212 only.)
Patient arrives at a local hotel for 2-week vacation. On Day 2, patient complains of abdominal pain and locates a local physician. The patient is examined and an expanded focused history is performed, exam is expanded problem focused, and MDM is low.
99213 (According to CPT guidelines: Hx - Expanded Problem Focused - 99213 Exam - Expanded Problem Focused - 99213 MDM Low - 99213 2 of 3 components must be met. Therefore, level is 99213.)
Office visit for known asthmatic for regular follow-up. No complaints other than shortness of breath with exercises, resolving with nebulizer treatment x2. No fatigue, no chest pain. Exam includes respiratory, cardiovascular, ENT, and constitutional. Asthma controlled.
99213 (An established patient visit would be assigned 99213 or 99214 only. Because the history and exam are not detailed of the affected system, the hx/exam would qualify for expanded problem focused only. Therefore, the visit would qualify for 99213 only.)
A 3-year-old established patient with complaints of stomachache after dinner at home. Patient had pasta 3-4 hours ago and began experiencing nausea and vomiting. No respiratory symptoms. No past history of abdominal problems. Patient has history of bilateral ear tube placement. Exams of ENT, abdomen, and chest, and constitutional are performed. Abdomen series negative, labs negative. Patient prescribed Compazine for N/V, with diagnosis of food poisoning.
99213 (Because the patient is established, the only correct answer could be 99213.)
Patient presents for shoulder pain of 3-4 weeks duration. Detailed history, expanded problem-focused exam, and MDM of low complexity were performed.
99213 (Expanded problem-focused exam and low MDM meet minimum 2/3 elements for 99213.)
Office visit for an established patient who presents with new onset of left upper quadrant pain following fall 2 weeks ago. Exam of abdomen and extremities was performed. Abdominal x-rays were negative. Diagnosis: Abdominal pain
99213 (For an established patient, only 99213 or 99214 would be appropriate. As the history and exam were not detailed, the visit would be considered expanded problem focused, 99213.)
A 7-year-old established patient with sore throat and headache for the past several days presents to physician's office. Patient afebrile. Has retro TM fluid left ear. Lungs are clear, heart, regular rate of rhythm. Impression: strep tonsillitis. Will treat with antibiotics.
99213 (Hx - Expanded Problem Focused - 99213 Exam - Expanded Problem Focused - 99213 Medical Decision-Making - 99214 Since this is an established patient, two of the three elements are required, and therefore, the level would be assigned 99213.)
An established office visit of a 56-year-old female with multiple medical problems. History includes three HPI elements, PMH, two ROS, two exam elements, and low medical decision-making.
99213 (Hx - Expanded Problem Focused - 99213 Exam - Expanded Problem Focused - 99213 Medical Decision-Making - Low - 99213 All three elements meet 99213; therefore, this would be the correct level for this scenario.) WRONG
An established patient presents to the office with fever, on and off for 2 days. Some chills and urinary urgency. Denies sore throat, nausea, vomiting, cough. Some low back pain and headache occasionally with fever. PMH: Htn; social: married, nonsmoker. Exam performed expanded problem focused. Medical decision-making, chest X-ray, U/A. Patient will be treated with Cipro for left lower lobe atelectasis and UTI.
99213 (Hx - Expanded Problem Focused - 99213 Exam - Expanded Problem Focused - 99213 Medical Decision-Making - Moderate - 99214 Qualifies for only an expanded problem focused exam as there is no detailed exam documented of the affected system. As only two of the three elements must be met for an established patient, this visit qualifies for 99213.)
A 9-year-old established patient with sore throat and cough for about a week. Temperature 101.4. Skin clear, pharynx red. Cultures taken. Negative strep. Chest clear. Heart tones regular. Abdomen soft. URI with pharyngitis, Amoxicillin 250 mg tid for 10 days.
99213 (Hx - Problem Focused - 99212 Exam - Expanded Problem Focused - 99213 Medical Decision-Making - Moderate - 99214 As this is an established patient office visit, only two of the three elements must be met, therefore, qualifies for 99213.)
Patient arrives with complaints of abdominal pain. History taken indicated lower abdominal pain started 4 days ago following long trip in automobile. What level of HPI has been performed?
99213 (Hx Present Illness would be considered Expanded Problem Focused. Detailed would involve a more detailed history including Past Medical, Social and/or Family History as well as an extended review of systems, which was not present. Therefore, 99213 would be assigned for an expanded problem-focused history as documented.)
Office visit for known diagnosis of hypertension who now presents with symptoms of fatigue and 2-week history of headache. Past history of diabetes and CAD. Cardiovascular, respiratory, and neurologic exams are negative. Patient given beta-blocker for HTN and hypertension-associated headaches.
99213 (Patient is an established patient; therefore, 99213 or 99214 are the only possible correct answers. Since a detailed hx/exam of the affected system was not documented, the visit would be considered expanded problem focused, which codes to 99213.) WRONG
ED visit with expanded problem-focused history and exam, limited by patient's medical condition and high MDM performed. What level would be assigned?
99285 (CPT guidelines indicate if Hx/exam limited by patient's condition and MDM is high, may assign 99285.)
A 56-year-old established patient with ear pain after swimming over weekend. Ear pain accompanied by fever, up to 102. No respiratory symptoms, however, has a past history of extensive otitis media. Exams are ears, nose, and throat as well as chest, constitutional. Diagnosis of otitis media and Rx for antibiotics.
99213 (Patient is an established patient; therefore, only 99212, 99213, and 99214 are possible correct answers. Since the hx/exam are not documented as detailed review of the affected system, however, do extend beyond the affected system (which would be problem focused), the visit would be considered expanded problem focused and assigned 99213.)
Established patient office visit for complaint of knee pain and swelling for 2-week duration. Red and painful swollen knee, with no swelling or pain in other joints, no fever, no fatigue. Exam of both knees, constitutional, neurologic exam. X-rays revealed osteoarthritis of both knee joints. Rx NSAID
99213 (Patient is an established patient; therefore, only 99213 or 99214 could be correct. The other codes are for new patients. Neither history nor exam would be considered detailed because they do not contain a detailed description of the affected system. Therefore, the visit would be considered expanded problem focused, 99213.) WRONG
A 43-year-old established patient with complaints of rash appeared approximately 2-3 days ago after trip to the country. No other problems such as fatigue, joint pain. Exam reveals diffuse rash over the legs, arms, and back. Rx for steroid application to affected areas. Assessment: rash of unknown etiology.
99213 (Patient stated as established; therefore, the only possible correct answers would be 99212 or 99213. Hx - Expanded Problem Focused - beyond affected system Exam - Problem Focused to skin only MDM - Moderate - New problem with Rx medication Therefore, a minimum of two of the three elements must be met. Assign 99213.) WRONG
A 13-year-old established patient injured his lower back on the left side when he reached back to catch a football. Since then, he has had lower back pain. PMH, back pain, heart murmur. ROS: sleep problems, no change since last visit and back pain, no meds, allergies or social history. Physical exam: lower back, no motor, sensory nerve deficits, appropriate weight for height and age, well-oriented to time, space, person. Given ibuprofen 800 mg tid as needed and told to return if no improvement in 7-10 days.
99213 (Stated as an established patient; therefore, only 99212 or 99213 could be correct. 99212 is problem-focused history/exam. 99213 is expanded problem-focused history/exam. Since the history and exam extend beyond the area of the chief complaint, they would be considered expanded problem focused. Therefore, 99213 would be the correct answer.)
Patient presents with diagnosis of breast cancer. Expanded problem-focused history and exam and low MDM are performed. Patient has had recurrent problems over the past 5-6 years and a lengthy discussion regarding treatment options was held with the patient. Thirty-five minutes were spent with patient and 20 minutes spent discussing surgical options, chemotherapy, and radiation treatment options.
99214 (CPT guidelines indicate that when counseling/coordination of care constitutes 50% or more of the visit time, the elements of history, exam, and medical decision-making are not considered in arriving at the level. Therefore, the time indicated beside 99214 would be utilized to determine the level.) WRONG
A 24-year-old female with vaginal bleeding following fall presents to her physician's office. States she slipped and fell today and landed on her left side. Began having abdominal pain, vaginal bleeding. Denies vaginal discharge, menstrual cycle completed 7-10 days ago. ROS, five systems. SH/FH: noncontributory. Exam is performed of six systems, GU in detail, MDM is moderate.
99214 (Exam would be considered detailed because a detailed exam of the affected area and other related areas was performed and medical decision-making was moderate. Since the exam and medical decision-making both qualify for 99214, the level of history is not necessary to meet the 99214 for this encounter.)
Patient seen in pediatrician's office after falling at home. Patient complained of knee pain and had trouble walking. Knee x-ray ordered but no fracture or dislocation was demonstrated. Physician documented a detailed examination and history and decision-making of moderate complexity.
99214 (Since all three of the components (history, exam, and medical decision-making) have been met, 99214 would be assigned. History - Detailed (99214) Exam - Detailed (99214) Medical Decision-Making - Moderate (99214))
Patient is a 3-year-old new patient seen for a well-child examination. An age-appropriate history, exam, and anticipatory and risk factor guidelines are followed.
99382 (Preventive medicine, new patient ages 1-4, code 99382 would be utilized.)
In the outpatient setting, a detailed history and exam are performed on an established patient. Assign the appropriate E/M for this service.
99214 (Since two of the three required elements have been met for this encounter, 99214 would be assigned regardless of the MDM. Remember that the overarching criteria is a CMS criteria, which would not be taken into consideration for the CPC exam.)
Established patient presents for pre-op visit. He is scheduled for a liver transplant. The physician performs an expanded problem-focused history, detailed exam, and moderate MDM. What E/M would be assigned for this service?
99214 (Two of the three elements are required, therefore, detailed exam meets 99214 and moderate MDM 99214.)
Outpatient visit, detailed history, detailed exam, low MDM
99214 (Two of three elements needed, detailed history and detailed exam assigned 99214.) WRONG
A 54-year-old woman presents with stress at home. Issues regarding her current living situation with her boyfriend and her children caused the patient to be unable to sleep or concentrate. Talked with patient at length regarding her stress level, approximately 15 minutes, and prescribed Trazodone 25 mg to take 1-2 hours before bed for the next few nights. We scheduled her to see a psychologist visit next week to begin resolving. Total visit time was 25 minutes.
99214 (Visit based on counseling/coordinating care as 50% of time documented in counseling/coordination. Therefore, assigned 99214. CPT guidelines indicate when counseling/coordination of care drive the encounter, the history, exam, and medical decision making components are not considered in the assignment of the level.) WRONG
A 35-year-old female returns to her PCP to discuss results of an abnormal pap smear. The physician spends a total of 45 minutes discussing with the patient an abnormal pap smear and what options are available.
99215 (When 50% or more of a visit is spent in counseling/coordination of care, the visit may be assigned based on time. Therefore, visit would qualify for 99215. When visit is assigned based on counseling/coordination of care, the visit is determined solely by the time listed in CPT. History, exam, and medical decision-making are not considered in these instances per CPT.)
Admission to observation, 01/02 with admit on 01/03.
99218, 99221 (An observation admit would be assigned for 01/02 and a Hospital Inpatient Admit assigned for 01/03. With the exception of the answer choice "99218, 99221," all the remaining answers are incorrect because they do not represent an observation admit and hospital inpatient admit.)
Patient presents to the ED with wheezing and shortness of breath. ER performs a comprehensive history and exam and moderate MDM. The physician decides to place him in observation care for asthma exacerbation and will continue to see him there. What code would be assigned for this additional care?
99219 (All three elements qualify for 99219.) WRONG
Patient admitted to observation care on 01/01. Later the same day, the physician decides to admit the patient to acute care. Assign the appropriate service(s).
99221 (According to CPT guidelines, typically only one E/M is assigned per day. Therefore, in this instance, only the admit would be coded. The only correct answer in this scenario is 99221.) WRONG
Patient presents for admission with dehydration and uncontrolled diabetes. Detailed history and exam performed and moderate MDM.
99221 (Because the visit is an initial visit, all three elements are required. Since the History and Exam are stated as detailed, the visit is limited to 99221.)
Hospital admission for asthma exacerbation. Detailed history, detailed exam, and high MDM were performed.
99221 (Limited by detailed Hx (99221) and detailed exam (99221), all three elements must be met, therefore, 99221 only.) WRONG
A 59-year-old with chest pain. History of small vessel disease. Seen in office today with chest pain and sent for admission and further evaluation. Admission H & P reveals no Hx MI, negative heart cath 3 years ago. Has HTN and diabetes. Physical exam: VS stable, heart, abdomen, extremities, normal. EKG shows sinus rhythm, chest x-ray normal, cardiac enzymes normal. Admitted for further evaluation and treatment. Detailed Hx and exam are documented.
99221 (Only one E/M per day, therefore, would assign admit. Hx, exam detailed, MDM straightforward to low. Therefore, assign 99221 only.)
A 22-year-old seen in ER for chest pain and subsequently admitted by the same physician. Detailed Hx, detailed exam, moderate MDM.
99221 (Only one E/M per physician per day, therefore, admit 99221 as visit limited by detailed Hx/exam.)
Patient presents to ER with complaints of nausea and vomiting. He is seen and admitted. A detailed history, comprehensive examination, and moderate MDM are performed.
99221 (Only one E/M per physician per day, therefore, admit appropriate. Detailed Hx limits visits to 99221 as all three elements are required.) WRONG
Patient admitted to inpatient hospital for possible stroke. History of right-sided numbness and weakness, 2-week duration. No cough, no chest pain. Exam of respiratory, cardiovascular, neurological. CT of brain with contrast performed as well as labs, x-rays. Patient admitted for cardiovascular accident with neurologic symptoms. Hx/exam detailed.
99221 (Visit was performed as Initial Hospital Visit; therefore, 99221 would be the only appropriate answer for this scenario.)
Hospital admission of 01/01 with discharge on 01/05. Patient seen daily prior to discharge.
99221, 99231 x 3, 99238 (Because the patient was seen for a total of five days of service, a total of five codes would be appropriate. Therefore, 99221 would be assigned for 01/01 for the admission, 99231 x 3 for the subsequent hospital visits for 3 days, and 99238 for the discharge on 01/05.)
Patient admitted on 01/5, seen 01/06-01/09, and discharged on 01/10. Assign code(s) appropriately.
99221, 99231 x 4, 99238 (Without regard to the level for each date of service, the scenario should have one (1) admit code, a total of four (4) subsequent visit codes, and one (1) discharge code. Therefore, the only answer that meets that criteria is 99221, 99231 x 4, 99238.)
Hospital admission on 01/01, subsequent visits on 01/02, with discharge on 01/03.
99221, 99231, 99238 (Three services were provided on three separate dates of service, therefore three codes would be appropriate as follows: Admit for 01/01 - 99221 Subsequent Hospital Visit for 01/02 - 99231 Hospital Discharge for 01/03 - 99238)
Patient presents with complaints of fever, chills, chest pain, and cough. Physician performed a problem-focused history and exam and low medical decision-making and admitted the patient to the hospital for pneumonia. Physician sees the patient in the hospital where a comprehensive history and exam and moderate MDM are performed.
99222 (As usually one E/M is allowed per provider each day, the coder would assign the higher level of the visit and admission. Only one code is appropriate, therefore, the only possible answers would be 99222 (admit) or 99214 (office visit). CPT guidelines indicate the admit would be assigned in this instance as it would be considered the more significant service.)
Patient met in ER by his regular physician complaining of chest pain. After comprehensive history and exam and high MDM, the patient is admitted by his physician to rule out myocardial infarction.
99223 (Only one E/M assigned per physician per day, therefore, admit would be assigned. Qualifies for 99223 as all three components (Hx, exam, and MDM) were met.) WRONG
A new patient is seen in the office with chest pain. The physician performs a detailed history and exam. The decision is made to admit the patient to the hospital where a comprehensive history and exam performed with high medical decision making.
99223 (Only one E/M per provider per day is assigned, therefore, the admit would be assigned. Hx, exam, and MDM all meet 99223 level.) WRONG
Patient admitted to CCU for an acute MI. Admission included comprehensive history and exam and high MDM. Patient was seen for 2 subsequent days where an expanded problem-focused history and exam and moderate MDM were performed. Patient was discharged on day 4.
99223, 99232 x 2, 99238 (Admit is 99223, comprehensive/comprehensive, high. Visits are assigned 99232 for days 2 and 3, listed as 99232 x 2 and discharge is 99238.)
A physician is called in as a consultant for an inpatient in the hospital and a problem-focused history and exam are performed with straightforward medical decision-making.
99231 (All three elements qualify for 99231. As the documentation does not mention whether all the elements for a consultation were met (i.e., written request, referral, and written report back to the requesting physician), a hospital visit is assigned instead of a consultation.)
Patient is hospitalized for confusion for the past 3 days. Today, she is alert and oriented, her labs are reviewed, and continued treatment will be for congestive heart failure.
99231 (This is considered a subsequent hospital visit. As 99231 is the only subsequent hospital selection, it would be the correct answer. Initial visits are assigned for the first date of admission only.)
Subsequent hospital visit for uncontrolled diabetes. BS still indicate diabetes not adequately controlled. Expanded problem-focused history and exam performed and low MDM.
99232 (Condition not adequately controlled, 2/3 elements required, history and exam assigned 99232.)
Patient admitted yesterday. Today, seen by the physician who admitted the patient and detailed history and exam are performed with low MDM. What code should be assigned for the subsequent visit?
99233 (Two of three elements needed. Since history and exam meet detailed level, qualifies for 99233.) WRONG
Patient admitted/discharged from inpatient facility same day. Detailed history and exam and moderate MDM performed.
99234 (Because the patient was admitted and discharged on the same date of service, a code from the 99234 series would be assigned. Visit limited by detailed history and exam to 99234.)
Patient admitted on 01/01 and discharged later the same day.
99234 (Patients admitted and discharged the same day from inpatient or observation are assigned codes from the 99234 series. Therefore, the only correct answer would be 99234. CPT guidelines instruct that an admit and discharge are not appropriate on the same day, nor is a discharge the appropriate code for this scenario.)
Admission to observation unit, 11:00 AM with discharge at 11:00 PM same day
99234 (When the patient is admitted/discharged on the same date of service, the 99234--99236 series of codes would be utilized. Code 99234 is the only answer within this series, and therefore, is the only correct answer.)
Discharge summary: Patient was admitted 1 week ago due to episodes of increased shortness of breath and weakness. At discharge, patient is stable, will continue his or her digoxin 125 mg daily and all other meds as prior to admission.
99238 (Discharge planning code would be assigned. Since no time was documented, assumed less than 30 minutes.)
Patient admitted 2 days ago for uncontrolled diabetes. Diabetes now stable. OK to discharge after diabetes consult later this morning. Performed discharge exam and appropriate paperwork for discharge. What E/M service would be assigned?
99238 (Discharge visit, 99238 assigned. Because the documentation does not support that greater than 30 minutes were spent preparing the patient for discharge, 99238 only would be assigned.)
Patient is being discharged today after admission for atrial fibrillation. A total of 40 minutes was spent preparing the patient for discharge. What E/M should be assigned for this service?
99239 (As documentation reflects over 30 minutes was spent in preparing the patient for discharge, would qualify for 99239.)
Patient prepared for discharge including final exam, instructions for continuing care, and arrangements made for home health with a total of 45 minutes spent preparing the patient for discharge.
99239 (Discharge planning documented as greater than 30 minutes is assigned 99239.)
Patient referred for consult by PCP regarding right knee pain. Expanded problem-focused history and exam and low MDM were performed and no significant orthopedic diagnosis was made following diagnostic x-rays. A prescription for pain medication was written and the patient was discharged back to their PCP for additional evaluation and treatment if needed. Written documentation of referral, requesting physician, and written report to PCP are documented.
99242 (Visit would qualify as consultation as seen for request for expert opinion and sent back to PCP. Expanded PF Hx and exam, therefore, visit would be assigned 99242.
Patient is referred to our clinic today as a consult from the ER. Detailed history and exam and low MDM are performed. Written request, referring physician, and written report are documented.
99243 (All three elements qualify for 99243.)
A plastic surgeon is called to the ED to evaluate a patient with multiple facial fractures. He performs an extended history of present illness, an extended review of systems, and a social and past medical history. A physical exam is performed that includes respiratory, cardiovascular, and an extended examination of the skin and bony structures of the patient's face. MDM is moderate including decision for major surgery to repair the facial fractures. Documentation of request for consult, referring physician, and written report back to requesting physician are available.
99243-57 (Hx - Detailed - 99243 Exam - Detailed - 99243 Medical Decision-Making - 99244 All three elements must be met; therefore, 99243 would be assigned. Modifier -57 should be assigned for decision for surgery. Would be assigned outpatient consultation as services performed in the ED that are considered outpatient.) WRONG
Established outpatient consultation requiring comprehensive history and exam, moderate MDM. All the components needed for a consultation were met (i.e., referring physician, written referral, and written report back to the requesting physician).
99244 (All three elements meet 99244 consultation.)
Patient is referred by their insurance carrier for a second opinion consultation regarding osteoarthritis as her orthopedist has recommended a knee replacement. The evaluation consists of a comprehensive history, comprehensive exam, and moderate MDM.
99244-32 (All three elements qualify for 99244 level of service. Also assign modifier -32 as mandated service by insurance carrier.)
Inpatient visit requested by another physician in writing, followed by a written report back to the requesting physician. Detailed Hx, expanded problem-focused exam, moderate MDM.
99252 (Inpatient consultations are assigned from the 99251 to 99255 series. The elements are defined as: Hx - Detailed - 99253 Exam - Expanded Problem Focused - 99252 Medical Decision-Making - 99254 All three elements must be met; therefore, the consultation would be assigned 99252.)
Consultation performed on inpatient setting, comprehensive history, detailed exam, low MDM. Documentation includes written referral, referring physician, and written report back to requesting physician.
99253 (Defined as an inpatient consultation, would require all three elements be met. Hx - Comprehensive - 99255 Exam - Detailed - 99253 Medical Decision-Making - 99253 Therefore, would qualify for 99253 only.)
Patient seen in the ER for laceration to hand, laceration to head with head trauma, concussion with loss of consciousness. Lacerations are repaired and physician examines the head, eyes, and ENT as well as takes a history regarding loss of consciousness, review of systems involves eyes, ears, neurological status. Medical decision-making is low. What code(s) would be appropriate?
99281-25, laceration/closure code (Visit took place in the ED, therefore, 99281-25 would be assigned as well as laceration/closure. HPI qualifies as straightforward only, therefore. Since all three components, such as Hx, exam, and MDM, must be met, the visit qualifies for 99281-25 only.)
ED visit, detailed history, detailed exam, low MDM
99282 (Emergency Department visits require all three components be met. As the medical decision making is defined as low, the level would only qualify for 99282 as defined by elements in CPT.)
Patient arrives at the ER from an auto accident. Detailed history, detailed exam, and low MDM performed.
99282 (Hx - Detailed Exam - Detailed Medical Decision Making - Low CPT guidelines indicate that all three elements must be met for ER visits; therefore, the visit is limited to 99282 due to low medical decision making.) WRONG
An 82-year-old presents to the ER with episodes of shortness of breath when supine intermittently for the last few weeks. States feels OK until he lies down and tries to sleep. Denies chest pain, lower extremity swelling but has had a dry cough for several days. Past history of atrial fib and COPD. Denies feeling of lightheadedness. Exam: VS, lungs, heart, abdomen, extremities. EKG: normal sinus rhythm. CXR: signs of COPD present. Multiple cloudings on x-ray. Diagnosis: exacerbation of COPD.
99283 (Hx - Expanded Problem Focused - 99283 Exam - Expanded Problem Focused - 99283 Medical Decision-Making - Moderate - 99284 Because Emergency Department visits require all three elements be met, the level would be considered 99283.)
A 10-year-old presents having fallen approximately 2 hours ago. Ice was applied, however, swelling and pain continues. ED physician performs ROS involving four systems. Patient lives at home and attends grade school in the area. Multiple systems are evaluated. Multiple x-rays are obtained as well as labs and independent evaluation of x-rays and discussion of case with another health care provider. The ED physician performs conscious moderate sedation for 30 minutes that is monitored and documented appropriately. The fracture is reduced and casted by the orthopedist. What are the appropriate E/M services for the ED physician for this encounter?
99284-25, 99156, 99157 (Hx - Detailed - 99284 Exam - Detailed - 99284 Medical Decision-Making - Moderate - 99284 All three elements must be met. Therefore, the E/M would qualify for 99284. Modifier -25 would be appended as additional "significantly, separately identifiable service" was performed. In addition, moderate conscious sedation was performed by other than the performing physician. Therefore, 99156 and 99157 would be assigned as well.)
A 53-year-old unresponsive patient. Known history of lung ca. Found in sinus bradycardia. IV started, patient intubated at the scene. PMH: lung ca. Unable to elicit FH, SH, ROS from patient. Exam, no pulse, no respirations, no BP. Pupils fixed and dilated, corneal reflexes absent. Heart sounds not heard. Patient has been unresponsive for approximately 45 minutes and decision not to attempt further resuscitation and pronounced dead at 2:22 AM.
99285 (CPT Assistant states that when the patient is seen in the Emergency Department and the physician is unable to perform comprehensive history and/or exam but the medical decision-making is high, then it is appropriate to assign 99285. In this instance, the decision to not make further attempts at resuscitation and allow the patient to succumb to their illness is considered high, therefore, 99285 would be assigned.)
Patient arrives in the physician's office for exacerbation of asthma. During the wait to see the physician, the patient experiences extreme SOB and goes into respiratory arrest. The physician examines the patient, begins IV meds, and continues treating the patient until an ambulance arrives. Time documented treating the patient is 45 minutes.
99291 (Critical care is assigned for attending to the patient for 45 minutes, code 99291. Critical care may be assigned regardless of the location of service as long as the patient is critically ill.)
Physician called to floor to evaluate patient with sudden hypotension and weakness. She was admitted to CCU for an acute MI and hypotension. The physician spent a total of 56 minutes performing critical care services. What E/M services should be assigned?
99291 (Qualifies for critical care service 99291. CPT critical care time grid indicates 99291 is assigned for 30-74 minutes of critical care.)
Patient in ED has critical care services provided for a total of 1 hour 45 minutes. What E/M code(s) would be assigned?
99291, 99292 X2 (According to CPT critical care grid, a total of 105 minutes is assigned 99291, 99292 x2.)
Critical care provided for a critically ill patient with 2 hours documented.
99291, 99292 X2 (Per CPT Critical Care grid, 120 minutes of critical care is assigned 99291, 99292 x2.)
Physician called to the intensive care unit at the hospital for a patient in coronary crisis. The physician spent 90 minutes stabilizing the patient.
99291, 99292 x 1 (A total of 90 minutes of critical care time qualifies as 99291 and 99292 x 1 as listed in CPT critical care grid.)
Patient arrives with severe life-threatening injuries. Emergency physician provides one-on-one care for this patient for a total of 1 hour 40 minutes.
99291, 99292 x 1 (According to the critical care grid located in the CPT guidelines, critical care performed for 75-104 minutes should be assigned 99291 and 99292 x 1.)
A 49-year-old female had a knee replacement yesterday. Today, she suffers a cardiac arrest. Cardiologist responds and provides 1 hour 35 minutes of critical care, orders a chest x-ray and provided ventilation management.
99291, 99292 x 1 (CPT table for critical care indicates 95 minutes of critical care qualifies for 99291 and 99292 x 1 only. Per CPT definition of critical care, ventilation management and chest x-ray included in critical care services.) WRONG
A 5-year-old brought to the emergency department for near drowning. At the time of presentation, ER physician performs endotracheal intubation, blood gas, central venous catheter placement. A total of 35 minutes is documented attending to this critical 5-year-old. (Separately billable services have already been deducted from time.) What would be billed for this encounter?
99291-25, 36556, 31500 (In addition to critical care service, endotracheal intubation and central venous catheter are separately reportable. Therefore, assign 99291-25 as well as 36555 and 31500. Blood gas analysis is not separately reportable per CPT guidelines in Critical Care section.) WRONG
Admission of patient to skilled nursing facility involving comprehensive history, detailed exam, and moderate MDM
99304 (Admission to Skilled Nursing Facility would be selected from Nursing Facility Visits, Initial codes as follows: Hx - Comprehensive - 99306 Exam - Detailed - 99304 Medical Decision Making - 99305 Since all three elements must be met, would qualify as 99304 only.)
Reassessment of nursing facility patient being readmitted to skilled nursing facility following hospitalization for acute myocardial infarction involving comprehensive history and exam, low MDM.
99304 (Reassessment for nursing home for readmission assigned initial code. Limited by low MDM to 99304.)
Patient is readmitted to the skilled nursing facility after recent hospitalization. Readmission requires comprehensive reassessment and establishment of a new treatment plan. Additional medications, physical therapy, and changes in her daily treatment protocol are established by the physician with moderate MDM.
99304 (Without regard to the level of elements required, only one answer, 99304, is for an initial skilled nursing facility. When a patient is readmitted, CPT guidelines indicate an initial skilled nursing facility visit should be assigned. Therefore, the correct answer would be 99304.)
Follow-up consultation is performed in the nursing facility as certain test results were not available at the time of the last visit. What type of visit should be assigned?
99307 (This would be considered a subsequent nursing facility visit, and as such, only 99307 would be appropriate.)
An established 3-year-old patient presents for an annual exam. Comprehensive history, exam, and moderate MDM are performed based on American Academy of Pediatrics recommendations. Appropriate anticipatory guidance was provided during the encounter.
99392 (Preventive services for an established 3-year-old patient is assigned 99392.)
A 45-year-old established patient schedules appointment for annual exam. Comprehensive history and exam are performed during which time a GI ulcer is discovered. The patient is requested to return in 1 week for further evaluation and treatment of this problem.
99396 (Only 99396 is assigned as the GI ulcer was only diagnosed and not treated.) WRONG
A 59-year-old male for annual exam, established patient.
99396 (Preventive medicine visit for established 59-year-old codes to 99396.)
A 35-year-old new patient receives 45 minutes of counseling and risk factor reduction intervention.
99403 (Assigned from Counseling, Risk Factor Reduction section of E/M.)
Work disability evaluation performed by family physician. What E/M services would be appropriate?
99455 (Work disability assigned 99455.) WRONG
Premature newborn admitted to the hospital NICU. Baby remains unstable and critical for 2 days after admission.
99468, 99469 x 2 (Initial critical care neonatal day is assigned 99468, subsequent days of neonatal critical care is assigned 99469.)
Neonatologist called to attend birth of 29-week gestation. Endotracheal intubation was performed and umbilical catheterization for insertion for fluids. The critically ill neonate was moved to NICU. A total of 45 minutes was spent attending to this critically ill infant. What services would be coded for the neonatologist?
99468-25, 31500, 36510 (Assign 99468-25 for critical care as well as endotracheal intubation 31500 and umbilical catheterization for IV 36510. Delivery/birth room resuscitation not appropriate as services described in CPT code 99465 not met.) WRONG
A 10-day-old infant is seen in the ED in respiratory distress. He is admitted and intubated with ventilation management. An echocardiogram was performed and read by the physician as congenital heart disease. What are the appropriate codes for the physician?
99468-25, 93304-26 (Patient still considered neonate; therefore, 99468-25 would be assigned. Per CPT, ventilation management is included. Also assign 93304 for echo performed (interpretation only requires appending modifier -26). When information to substantiate a complete echo is not documented, the least significant, limited, would be assigned.)
Chronic care management for a 74-year-old patient with debilitating arthritis and CAD, 25 minutes via phone during the calendar month.
99490 (Management for chronic care for two or more conditions, with 25 minutes spent during the calendar month assigned 99490.)
How does CPT define an emergency department?
Hospital-based facility for provision of unscheduled episodic services for immediate medical care. Facility must be available 24 hours a day.
Why are the following codes not reported with continuing intensive care services: 43752, 94660, 36000?
Included in continuing intensive care services (Those service are included in continuing intensive care services. Refer to the Continuing Intensive Care Services in the E/M section of CPT for inclusions/exclusions.)
Patient arrives with complaints of neck pain radiating into shoulder and hand. Expanded problem-focused history and exam are performed with low MDM. Cervical spine x-rays are performed and interpreted. Codes 99213 and cervical spine x-ray, code 72040, are performed in the office. What modifier(s), if any, is appropriate?
No modifier (No modifier is necessary as x-rays are not considered a surgical procedure and commonly performed with an E/M.)
Telephone evaluation and management for 10 minutes as follow-up to visit yesterday in the office. What E/M services would be appropriate?
None (Telephone E/M services are NOT assigned when follow-up to previous visit, therefore, no E/M would be assigned.)
Telephone evaluation and management services performed with follow-up next morning in office. What E/M services would be appropriate?
None (Telephone E/M services are NOT assigned when follow-up visit next day, therefore, no E/M would be assigned.)
How does CPT define a new patient?
Patient who has not received professional services from the physician of the same specialty in the same group in the last 3 years (CPT defines a new patient as any patient who has not received services from physician in same specialty in same group in the last 3 years.)
What requirements are necessary for a consultation? Written Report all components listed Referring Physician Request for Consultation
all components listed (A referring physician, request for a consultation, and written report are all required for a consultation.)