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