Practicum: Module 12: Evaluation and Management Section of CPT

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. 99242 99201 99213 99212

99201 Visit is limited by problem-focused history and exam. Assign 99201 only. Does not qualify for consultation as patient was self-referred.

New patient outpatient visit, detailed Hx, expanded problem-focused exam, MDM moderate. 99203 99202 99201 99213

99202

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. 99214 99213 99204 99202

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 - 99202Exam - Expanded Problem Focused - 99202Medical Decision Making - Moderate - 99204 Therefore, since all three elements must be met, would qualify as 99202 only.

What modifier is utilized to indicate an E/M is a "significantly, separately identifiable service"? -22 -25 -24 -21

-25

Patient seeks second opinion for possible hysterectomy. New patient presents to office where a detailed history and exam are performed and moderate MDM. 99214 99203 99204 99213

99203

A 70-year-old presents to the OB/GYN office for recheck of previously placed pessary placement by nurse. 99202 99211 99201 99212

99211

Office visit for dressing change to leg performed by physician's nurse. Patient seen previously for wound, result of fall from bike. 99112 99211 99213 99212

99211

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. 99201 99212 99213 99214

99212

Established patient seen for earache. History and exam are problem focused and MDM is low. Diagnosis of otitis media, right is made. 99201 99213 99203 99212

99212

Office visit for an established patient. Problem-focused history and exam, straightforward MDM. 99213 99212 99211 99201

99212

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. 99285 99222 99221 99284

99221 Only one E/M per physician per day, therefore, admit appropriate. Detailed Hx limits visits to 99221 as all three elements are required.

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. 99202 99213 99211 99212

99212

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. 99201 99203 99202 99213

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. 99212 99213 99202 99203

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. 99214 99203 99213 99202

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 99203 99212 99202

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.

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 99212 99203 99202

99213 Patient stated as established; therefore, the only possible correct answers would be 99212 or 99213. Hx - Expanded Problem Focused - beyond affected systemExam - Problem Focused to skin onlyMDM - Moderate - New problem with Rx medication Therefore, a minimum of two of the three elements must be met. Assign 99213.

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 99203 99213 99204

99214

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. 99203 99202 99213 99214

99214

Admission to observation, 01/02 with admit on 01/03. 99221 99217, 99221 99234, 99221 99218, 99221

99218, 99221

Patient presents for admission with dehydration and uncontrolled diabetes. Detailed history and exam performed and moderate MDM. 99222 99223 99214 99221

99221

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. 99213-25, 99221 99221 99214 99223

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. 99282 99222 99221 99284

99221 Only one E/M per physician per day, therefore, admit 99221 as visit limited by detailed Hx/exam.

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. 99214 99221 99223 99217

99221 Visit was performed as Initial Hospital Visit; therefore, 99221 would be the only appropriate answer for this scenario.

Subsequent hospital visit for uncontrolled diabetes. BS still indicate diabetes not adequately controlled. Expanded problem-focused history and exam performed and low MDM. 99233 99231 99232 99221

99232

Patient admitted/discharged from inpatient facility same day. Detailed history and exam and moderate MDM performed. 99234 99221 99222 99238

99234

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 99233 99232 99239

99238

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. 99238 99221 99217 99239

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. 99213 99242 99241 99252

99242

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). 99243 99263 99244 99245

99244

Consultation performed on inpatient setting, comprehensive history, detailed exam, low MDM. Documentation includes written referral, referring physician, and written report back to requesting physician. 99243 99252 99251 99253

99253 Defined as an inpatient consultation, would require all three elements be met. Hx - Comprehensive - 99255Exam - Detailed - 99253Medical Decision-Making - 99253 Therefore, would qualify for 99253 only.

ED visit, detailed history, detailed exam, low MDM 99281 99284 99282 99283

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.

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. 99221 99282 99283 99285

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 99284, 99151, 99152 99283-25, 99156, 99157 99283

99284-25, 99156, 99157

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 99283 99282 99284

99285 CPT guidelines indicate if Hx/exam limited by patient's condition and MDM is high, may assign 99285.

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. 99215 99288 99291 99289

99291

Critical care provided for a critically ill patient with 2 hours documented. 99291 99291, 99292 X2 99292 X2 99291, 99291

99291, 99292 X2

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 X2 99291, 99292 X2 99291 99291, 99292

99291, 99292 X2 According to CPT critical care grid, a total of 105 minutes is assigned 99291, 99292 x2.

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. 99238 99304 99239 99313

99304

Admission of patient to skilled nursing facility involving comprehensive history, detailed exam, and moderate MDM 99309 99304 99305 99308

99304 Admission to Skilled Nursing Facility would be selected from Nursing Facility Visits, Initial codes as follows: Hx - Comprehensive - 99306Exam - Detailed - 99304Medical Decision Making - 99305 Since all three elements must be met, would qualify as 99304 only.

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 99241 99232 99251

99307

A 59-year-old male for annual exam, established patient. 99386 99385 99395 99396

99396 Preventive medicine visit for established 59-year-old codes to 99396.

Work disability evaluation performed by family physician. What E/M services would be appropriate? 99242 99455 99456 99201

99455

Premature newborn admitted to the hospital NICU. Baby remains unstable and critical for 2 days after admission. 99469 x 2 99471, 99472 99468, 99469 x 2 99468 x 2

99468, 99469 x 2

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, 99464 99465, 99468 99465, 99464, 99468-25, 31500, 36510-51 99468-25, 31500, 36510

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.

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? 99291-25, 93303 99471-25, 31500, 94002, 93303 99468-25, 93304-26 99460-25, 31500, 94002, 93303

99468-25, 93304-26

Chronic care management for a 74-year-old patient with debilitating arthritis and CAD, 25 minutes via phone during the calendar month. 99455 99489 99490 99487

99490

Telephone evaluation and management for 10 minutes as follow-up to visit yesterday in the office. What E/M services would be appropriate? None 99443 99442 99441

None

Telephone evaluation and management services performed with follow-up next morning in office. What E/M services would be appropriate? None 99443 99441 99442

None

What requirements are necessary for a consultation? Referring Physician all components listed Written Report Request for Consultation

all components listed