If The Dr Didn't Say It Didnt Happen
Code What You See
Study Smarter Not Harder
Keep It Simple
Overthinking Is Not Ok
100
1. Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days. a. Location, severity and duration b. Location, quality and duration c. Quality, severity and timing d. Quality, duration and timing
B - Location (headache), quality (blurry), duration (past three days).
100
11. 32 year old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported? a. 99203 b. 99214 c. 99242 d. 99243
C - The three R’s of consultation are documented (request, render, reply). The consultation code range is 99241-99245, and applies to new or established patients. Consultations require three key components. The documentation states the history and exam were expanded problem focused and the MDM is straightforward. These three key elements meet the requirement for 99242.
100
21. After moving across country, Ms. Robbins took her two-year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age / gender appropriate history, exam, and provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported? a. 99381 b. 99382 c. 99391 d. 99392
B - This is a new patient to the pediatric clinic. Look in the CPT® Index for Preventive Medicine/New Patient and you are directed to code range 99381-99387. The code selection is based on age. Code 99382 is for ages 1-4 making it the correct code choice.
100
31. Subjective: Six-year-old girl twisted her arm on the playground. She is seen in the ED complaining of pain in her wrist. Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal Assessment: Wrist sprain Plan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement. What is the E/M code for this visit? a. 99221 b. 99284 c. 99241 d. 99281
D - Emergency Department services must meet or exceed three of the three key components. The physician performed a problem focused history (brief HPI, no ROS, no PFSH), a problem focused exam (one body area is examined), and low MDM (for one new problem to the examiner, one data point for the X-ray, and low level of risk). The problem focused history and exam lead us to select 99281 as the appropriate code.
100
41. The physician was called to the hospital floor for the medical management of a 56-year-old patient admitted one day ago with aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypenic yesterday; lungs reveal course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support. He reviewed chest X-ray and labs. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported? a. 99218 b. 99221 c. 99232 d. 99231
D - Physician is providing subsequent hospital care to an inpatient. The physician performed an expanded problem focused interval history (brief HPI, pertinent ROS since last assessment) + problem focused exam (1 system) + low MDM (prescription drug management, two data points and established diagnosis is improving. Subsequent hospital codes require two out of three key components. The code documented is a 99231.
200
3. Fred is fishing at the local area lake while on vacation. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. He’s evaluated by the ED physician. This is the first time he has been to this hospital. What subsection should be used to report the ED visit? a. Office or Other Outpatient Services; New Patient b. Emergency Department Services c. Initial Hospital Care d. Office or Other Outpatient Consultations
B - No distinction is made between a new and or an established patient in the emergency department. An Evaluation and Management service provided in an Emergency Department is reported with codes from the Emergency Department Services Subsection 99281-99285.
200
13. When tissue glue is used to close a wound involving the epidermis layer how is it reported? a. As though it was a simple closure b. As a 99211 c. It is not billable d. As though it was a complex closure
A - The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singley or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code.
200
23. 10 year old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat, and stuffy nose for the past two days. The physician performs a complete physical and evaluates and treats the patient for a URI. What CPT® code(s) is/are reported for this visit? a. 99393 b. 99393, 9921X-25 c. 9921X d. 99393-25, 9921X
B - The physical exam code is selected from the Preventive Medicine Services and selected based on whether the patient is new or established and by age. The pediatrician also evaluates and treats the URI. The additional work for the URI allows us to report an established patient office visit. Modifier 25 is appended to the office visit to show it is a significant and separately identifiable service from the preventive visit.
200
33. Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR. The time the provider spent on CPR was 15 minutes. What are the appropriate procedure codes for this encounter? a. 92950, 99291, 99288 b. 99291, 99292, 99288 c. 99291, 99288 d. 92950, 99291
A - Documentation describes physician direction of the paramedics (99288) In the CPT® Index, look for Physician Services/Direction, Advanced Life Support. He spends another hour stabilizing the patient, reported with critical care code 99291. The time for the CPR must be deducted from the 1 hour of critical care, making the critical care time 45 minutes, so 99291 is reported. In the CPT® Index, look for Critical Care Services. CPR is not a service included in the critical care codes and may be reported separately with 92950.In the CPT® Index, look for CPR (Cardiopulmonary Resuscitation). See the CPT® guidelines under Critical Care Services.
200
43. An established 47-year-old patient presents to the physician’s office after falling last night in her apartment when she slipped in water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Physician documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Doctor’s Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service? a. 99212, S39.012A, W18.30XA, Y92.030 b. 99213, S39.012A, W01.0XXA, Y92.030 c. 99213, S33.9XXA, W18.40XD, Y92.030 d. 99212, S39.012A, W19.XXXD, Y92.030
B - The patient is an established patient. In the CPT® Index, look for Established Patient/Office and/or Other Outpatient/Office Visit. You are referred to 99211-99215. An established patient visit requires 2 of 3 key components. The physician documents an Expanded Problem Focused History (brief HPI, pertinent ROS, and no PFSH), a Problem Focused Exam (1 affected organ system, musculoskeletal) and Low MDM (New Problem to examiner, no additional work-up, 0 data points, and acute complicated injury, e.g., simple sprain). Review codes to choose the appropriate level of service. Code 99213 is the correct code. Lower Back Muscle Strain was the doctor’s diagnosis. In the ICD-10-CM Index to Diseases and Injuries, look for Strain/low back. You are referred to S39.012-. Tabular List shows that a 7th character is reported. A is reported for the initial encounter. Next go to the External Causes of Injuries Index. Look for Slipping (accidental) (on same level) (with fall). You are referred to W01.0-. In the Tabular List placeholders of X are needed for the fifth and sixth characters. The 7th character is reported for A to indicate initial encounter A. Next look for Place of occurrence/residence/apartment/kitchen. You are referred to Y92.030. Review the code in Tabular List to verify accuracy
300
5. Where are clinical examples for evaluation and management codes found in CPT®? a. CPT® Assistant b. Appendix A c. Appendix B d. Appendix C
D - Appendix C of CPT® contains clinical examples of evaluation and management codes. It may be used in addition to the code descriptors.
300
15. A patient is in the hospital after a wedge resection of the left lung cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient’s family is not present. What CPT® code is reported? a. 99252 b. 99366 c. 99367 d. 99368
C - In CPT® Index, look for Conference/Interdisciplinary Team and you are directed to code range 99367-99368. 99367 is reported for a medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. All providers listed in the scenario are physicians; 99367 is the correct code.
300
25. The physician admitted an 18-month-old infant to the hospital from his office to rule out sepsis. The infant is crying inconsolably. He has a large amount of gas in his bowel, no hematochezia associated with it. A comprehensive history, comprehensive exam, and moderate decision making is documented If cultures are negative and the patient remains afebrile, for 48 hours the infant will be discharged home. What CPT® code is reported for this visit? a. 99222 b. 99219 c. 99238 d. 99223
A - According to CPT® guidelines: “When the patient is admitted to the hospital in the course of an encounter in another site of service (eg, hospital emergency, department, physician's office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.” The physician admitted the infant to the hospital from his office and continued the care on the same date of service. The physician documented a comprehensive history, comprehensive exam, and moderate MDM. The appropriate code is 99222.
300
35. 28-year-old female patient is returning to her physician’s office with complaints of RLQ pain and heartburn with a temperature of 100.2. The physician performs a detailed history, detailed exam and determines the patient has mild appendicitis. The physician prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter? a. 99214, K37, R12 b. 99202, R10.31, K37 c. 99213, K37 d. 99203, R50.9, R12, R10.31, K37
A - This is an established patient E/M level of service due to the indication she returning to her physician for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD-10-CM Official Coding Guidelines Section I.B.6-8, a definitive diagnosis is reported when it has been established. Look in the ICD-10-CM Index to Diseases and Injuries for Appendicitis K37. Any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code. Look in the Index to Diseases and Injuries for Heartburn R12. Verification in the Tabular List confirms code selections.
300
45. Dr. X asks Dr. Y to look at a 65-year-old male who is in a nursing facility for decubitus ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a detailed history from Dr. X since the patient is unable to provide a history. A detailed exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to the surgical suite for debridement of the ulcerations. Since the patient is unstable at the moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep monitoring the patient until he stabilizes. Written report is documented. What CPT® code is reported? a. 99304 b. 99234 c. 99243 d. 99253
D - Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing facility. According to CPT® guidelines: “The initial inpatient consultation codes (99251-99255), are to be used only once by the reporting physician for an individual hospital or nursing facility patient for a particular admission. These codes are to be reported for consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting.” A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and /or management of a specific problem is requested by another physician. The consulting physician performs the consultation, documents his or her opinion in the patient's medical record, and communicates findings/recommendations by written report to the requesting physician or other appropriate source. Consultations require the documentation of three of three key components. The provider performed a detailed history, detailed exam and moderate MDM. The correct code is 99253.
400
7. According to CPT® guidelines, what is the first step in selecting an evaluation and management code? a. Determine the level of history b. Determine the level of medical decision making c. Determine the category or subcategory d. Determine if time is the determining component
C - According to the CPT® guidelines, the first step to determining a level of evaluation and management visit is to determine the category or subcategory of service.
400
17. A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma. Admit date/time: 01/21/20XX 8:12 PM Detailed History, Detailed Exam, Low MDM Discharge date/time: 01/22/20XX 8:15 AM Discharge time: 20 minutes What CPT® code(s) is/are reported for the admission and discharge to Observation Care? a. 99234 b. 99221, 99238 c. 99217 d. 99218, 99217
D - Although the patient was in observation for less than 24 hours, the service covered two dates of service. The Observation care discharge day management code – 99217 – says this code is to be utilized to report all services provided to a patient on discharge from ‘observation status if the discharge is on other than the initial date of ‘observation status.” Initial Observation care is reported with code range 99218-99220. The level of history, exam and medical decision making support level 99218. Code 99217 is reported for Observation care discharge.
400
27. A physician makes a home care visit to a 63-year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home-bound for the last year. The last visit from this physician was four months ago to manage his DM. The physician performs an expanded problem focused examination and low MDM. The physician speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported? a. 99213 b. 99342 c. 99348 d. 99335
C - According to CPT® E/M guidelines, Home Services codes (99341-99353) are used to report evaluation and management services provided in a private residence. This is an established patient to the physician. Established patient home care codes require two of three key components. The physician performed an expanded problem focused exam and low MDM resulting is code 99348.
400
37. 37-year-old female is seen in the clinic for follow-up of lower extremity swelling. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension. Exam: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics, it may be secondary to problem #2. 2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist. PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study. a. 99213 b. 99212 c. 99214 d. 99215
B - This is a follow up visit indicating an established patient seen in the clinic. In the CPT® Index, look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History – PF (HPI-Brief, ROS-None, PFSH-Pert), Exam – Problem Focused, MDM – Moderate (Mgmt options - 1 stable problem, one new problem with workup; Data reviewed – lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported.
400
47. 90-year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported? a. 99235 b. 99217 c. 99238 d. 99221
A - This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service should be reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 should be reported as appropriate.” The provider performed a comprehensive history, comprehensive exam and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.
500
9. A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B? a. Established patient office visit b. New patient office visit c. Office consultation d. Preventive medicine visit
A - According to the E/M Guideline for New and Established Patient, when a provider is on call or covering for another provider, the patient’s encounter will be classified as it would have been by the provider who is not available. In this instance, Dr. B would report an established patient office visit.
500
19. The EMS brought a 31-year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam, and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported? a. 99282 b. 99283 c. 99284 d. 99285
D - In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.
500
29. Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone’s new diagnosis of Hodgkin’s lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit? a. 99213, 99354 b. 99215 c. 99202, 99354 d. 99203
A - This is an established patient. Two of the three key elements are required for an established patient. An expanded problem focused exam and moderate MDM meet or exceed the requirement for code 99213. The physician spent an additional 45 minutes with the patient discussing the patient’s new diagnosis. Prolonged Service codes 99354-99357 are used when physician or other qualified heath care professional provides prolonged service involving direct patient contact that is provided beyond the usual service. The codes reported based on the place of service and total time. Codes 99213 and add-on code 99354 are used to report the services.
500
39. 33 year-old male was admitted to the hospital on 12/17/XX from the ER, following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending physician performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The physician spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit? a. 99221 b. 99231 c. 99238 d. 99283
C - The patient is being discharged from the hospital. Hospital discharge codes are determined based on the time documented the physician spent providing services to discharge the patient. The provider documented 20 minutes, which is reported with 99238.
500
49. Subsequent Hospital Visit CHIEF COMPLAINT: CHF INTERVAL HISTORY: CHF symptoms worsened since yesterday. Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I’m concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome. REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins. PHYSICAL EXAMINATION: GENERAL: Mild respiratory distress at rest VITAL SIGNS: BP 168/84, HR 58, temperature 98.1. LUNGS: Worsening bibasilar crackles CARDIOVASCULAR: RRR, no MRGs. EXTREMITIES: Show worsening lower extremity edema. LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12. IMPRESSION: 1. Severe exacerbation of CHF 2. Poorly controlled HTN 3. Worsening ARF due to cardio-renal syndrome PLAN: 1. Increase BUMEX to 2 mg IV Q6. 2. Give 500 mg IV DIURIL times one. 3. Re-check usual labs in a.m. Total time: 20minutes. What CPT® code should be reported? a. 99231 b. 99232 c. 99233 d. 99214
C - This is a subsequent hospital visit which is reported with code range 99231-99233. In the CPT® Index, look for Hospital Services/Subsequent Hospital Care, 2 of the 3 key components must be met to support a level of visit. Detailed history (Extended HPI + Extended ROS + 0 PFSH), EPF Exam (using 1995 documentation guidelines of a limited exam of 2-7 of affected BA/OS and other related OS), MedicalDecision Making (MDM) high complexity (extensive diagnoses and management and high- risk to the patient for complications). According to the documentation guidelines for E/M services, for the subsequent care category, CPT® requires only an “interval” history. It is not necessary to record information about the PFSH. The diagnoses are CHF, HTN and ARF due to cardio-renal syndrome. Code 99233 is the appropriate code.
M
e
n
u