1. A new patient in a physician’s office, Documentation supports for Brief History of present illness, Extended Review of the system and personal history of previous cardiac surgery with detailed examination and MDM of moderate complexity. Which level of E/M code supports this documentation?
A. 99203
B. 99204
C. 99202
D. 99214
2. A 37 yrs old female is brought to the Emergency Department due to snake bite. The ED physician performed comprehensive History & Examination and the MDM of moderate complexity. The ED physician decided to place her in Observation status, The ED physician will continue examining the patient and will order additional treatments until the patient recover. What CPT code should be reported for this service?
A. 99235
B. 99219
C. 99285
D. 99284
3. A 55 yr old male is being discharged today from the hospital, Dr Yun-zin admitted the patient for severe abdominal pain in the morning. CT of abdomen and pelvis shows ulcerative colitis. He has given follow up medications with diet counselling. Total time spent with the patient during discharge is 40 minutes. What CPT code should be reported?
A. 99239
B. 99234
C. 99221, 99239
D. 99221, 99234
4. Dr James performs a follow-up consultation for a 68 yr old female in his office for low back pain with radiating towards the right leg. Today the patient is feeling stable with the medications compare with the previous a consultation visit is done by the same physician two weeks ago. For today’s service documentation supports for problem-focused history, EPF exam and MDM of low complexity. What CPT code should be reported for Dr James?
A. 99242
B. 99212
C. 99213
D. 99241
5. A 2 yr old a boy is brought to the ER due to syncope. The ER physician performs Endotracheal intubation, blood gas and central venous catheter placement. The ER physician documents a total time of critical care is one hour 45 minutes. He has subtracted the other billable service’s time. How would you report this service?
A. 99291 – 25, 99292 x 2, 36555, 31500, 82803
B. 99291- 25, 36555, 31500, 82803
C. 99475 - 25, 36555, 31500, 82803
D. 99291 – 25, 99292 x 2, 36555, 31500
6. A 16 yr an old child is here for an annual physical exam. As per previous Immunization record Hep B vaccine was given 12 months ago by the different physician belongs to the same group. Documentation supports for four elements of HPI, complete ROS and three elements of PFSH. Detailed examination and MDM of moderate complexity. There is no abnormality noted during the visit, how would you report this service?
A. 99394
B. 99384
C. 99214 – 25, 99394
D. 99214
7. An 18 days old critically ill baby girl is seen in the Emergency Department by the neonatologist due to Bradypnea and cyanosis later he admitted the patient into the NICU and provided critical care service. The same physician performs the intubation and ventilator management in the NICU. An echocardiogram is performed, results show the congenital septal defect. How would you report this service?
A. 99468 - 25, 93303 – 26
B. 99468 – 25, 31500, 94002, 93303 - 26
C. 99477 – 25, 31500, 94002, 93303 – 26
D. 99291 – 25, 93303 – 26
8. A 49 yrs old female, an established patient coming to meet the physician in his office with severe right lower quadrant pain. The physician performs an EPF History, detailed examination and MDM of moderate complexity. After the evaluation physician spends an additional 45 min with the patient in answering her queries. How would you report this service?
A. 99213, 99356
B. 99214, 99354
C. 99213, 99354
D. 99214, 99356
9. A 28 yrs old patient presents with right ankle pain and swelling following a fall from the ladder. The injury occurred today morning around 9am. He applied ice but there is a huge swelling at the inner side of the ankle. In the Emergency Department physician performs a six system ROS. The patient is a chain smoker, married recently and no personal history of previous injuries. The physician performed a seven system exam. MDM of moderate complexity. An X-ray is ordered, which shows a bimalleolar fracture. The ED physician performs moderate conscious sedation with ketamine for 30 minutes. The fracture is reduced by the orthopaedic surgeon following consultation with the ED physician. Code the service performed by the ED physician?
A. 99284 - 25, 99152, 99153
B. 99283 - 25, 99156, 99157
C. 99283 - 25, 99152, 99153
D. 99284 - 25, 99156, 99157
10. Mr John, an 82 yrs old-established patient is being seen today for chest pain and palpitation in the physician’s office. The PCP decided to send the patient with a request letter to get the second opinion from Cardiologist Dr Greg. This was the first time Dr Greg had seen Mr John in hospital outpatient settings, Dr. Greg documented Detailed History, comprehensive Examination and MDM of moderate complexity. Prescribed a few medications for his condition and he sent a report back to the primary care physician. How would you report Dr Greg visit?
A. 99244
B. 99214
C. 99243
D. 99203
11. Mrs Larry made a telephone call to physician office at 10.28 am to talk to a physician about her 12 months old child is suffering from cold, cough with mild sputum. The last visit with the physician was 8 days back for the immunization. Physician’s office staff attended the call and connected the call to the physician at 10.30 am and the call is completed at 10.39 am the physician has prescribed a few medications and asked the patients mother to come after one week if the condition has not improved. How would you report the service?
A. 99442
B. 99441
C. Service is invalid since the patient’s mother as initiated the call, not by the physician.
D. Telephone Call duration would be Included in the next office visit.
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Answer:
1. C
2. B
3. B
4. C
5. D
6. A
7. A
8. B
9. D
10. C
11. B