Evaluation and management

1. How does the CPT Professional Edition define a new patient?

a. A new patient is one who has not received any professional services from the
physician or another physician of the same specialty who belongs to the same
group practice, within the past two years.

b. A new patient is one who has not received any professional services from the
physician or another physician of the same specialty who belongs to the same
group practice, within the past three years.

c. A new patient is one who has received professional services from the physician
or another physician of the same specialty within the last two years for the same
problem.

d. A new patient is one who has received hospital services but has never been
seen in the clinic by the reporting physician.

2. James, a 35-year-old new patient, received 45 minutes of counseling and risk

factor reduction intervention services from Dr. Kelly. Dr. Kelly talked to James
about how to avoid sports injuries. Currently, James does not have any symptoms
or injuries and wants to maintain this status would you report this.This was the
only service rendered. How service?

a. 99213
b. 99203
c. 99385
d. 99403
3. Andrea, a 52-year-old patient, had a hysterectomy on Monday morning. That
afternoon, after returning to her hospital room, she suffered a cardiac arrest. A
cardiologist responded to the call and delivered one hour and 35 minutes of
critical care. During this time the cardiologist ordered a single view chest x-ray
and provided ventilation management. How should you report the cardiologist’s
services?
a. 99291, 99292
b. 99291, 99292, 71045, 94002
c. 71010, 94002, 99231
d. 99291, 99292, 99292-52

4. Brandon was seen in Dr. Shaw’s office after falling off his bunk bed. Brandon’s
mother reported that Brandon and his sister were jumping on the beds when she
heard a “thud.” Brandon complained of knee pain and had trouble walking. Dr.
Shaw ordered a knee x-ray that was done at the imaging center across the street.
The x-ray showed no fracture or dislocations. Dr. Shaw had seen Brandon for his
school physical six months ago. Today, Dr. Shaw documented medical decision-
making of moderate complexity. He also instructed Brandon’s mother that if
Brandon had any additional pain or trouble walking he should see an orthopedic
specialist.Time spent for today’s visit is 35 minutes. How should Dr. Shaw report
her services from today’s visit?

a. 99204 b. 99394, 99214 c. 99214 d. 99203

5. Adam, a 48-year-old patient, presented to Dr. Crampon’s office with complaints

of fever, malaise, chills, chest pain, and a severe cough. Dr. Crampon took a
history, did an exam, and ordered a chest x-ray. After reviewing the x-ray, Dr.
Crampon admitted Adam to the hospital for treatment of pneumonia. After his
regular office hours, Dr. Crampon visited Adam in the hospital where he dictated
medical decision-making of moderate complexity. Total time pent for this visit is
60mins .How would you report Dr. Crampon’s services?
a. 99214
b. 99222
c. 99204, 99222-51
d. 99223, 99214-21
6. Why are the following codes not reported with continuing intensive care
services (99478–99480): 36510, 36000, 43752, 51100, 94660, or 94375?
a. These codes are deleted from the 2008 edition.
b. These codes are included with continuing intensive care services.
c. These codes are only add-on codes and should be reported with a modifier -51
d. These codes are Category III Codes and should never be reported with Category
I codes.

7. Larry is being managed for his warfarin therapy on an outpatient basis. Dr.
Nancy continues to review Larry’s INR tests, gives patient instructions, dosage
adjustment as needed, and ordered additional tests. How would you report the
initial 90 days of therapy including 8 INR measurements?
a. 93793
b. 0074T
c. 99214
d. This services is bundled with evaluation and management services

8. Dr. Jane admitted a 67-year-old woman to the coronary care unit for an acute
myocardial infarction. The admission included high complexity decision-making.
Dr. Jane visited the patient on day two and three and documented (each day) a
decision-making of moderate complexity. On day four, Dr. Jane spend 25 minutes
of service time on this day and moved the patient to the medical floor and
documented straightforward decision-making . Day five, Dr. Jane discharged the
patient to home. The discharge took over an hour. How would you report the
fourth day of service?
a. 99213, 99232, 99231, 99239
b. 99221
c. 99232, 99355, 99217
d. 99231

9. Which code range would describe services for a critically ill patient who is 23
days old as a out patient?
a. 99291–99292
b. 99293–99294
c. 99295–99296
d. None of the above
10. Mr. Johnson, a 38-year-old established patient is being seen for management
of his hypertension, diabetes, and weight control. On his last visit, he was told he
had a diabetic foot ulcer and needed to be hospitalized for this condition. He
decided to get a second opinion and went to see Dr. Myers. This was the first time
Dr. Myers had seen Mr. Johnson. Dr. Myers documented a decision-making of
high complexity. He concurred with hospitalization for the foot ulcer and sent a
report back to Mr. Johnson’s primary care doctor. Total time spend for this
service was 65 minutes. How would you report Dr. Myers visit?

a. 99245 b. 99205 c. 99215 d. 99255

11. How does the CPT Professional Edition define an emergency department?
a. An organized hospital-based facility for the provision of unscheduled episodic
services to patients who present for immediate medical attention. The facility
must be available 24 hours a day.
b. An organized hospital-based facility for the provision of scheduled episodic
services to patients who present for immediate medical attention. The facility
must be available 24 hours a day.
c. An organized hospital-based facility for the care and treatment of chronically ill
patients who present for services. The facility must be available on weekends and
holidays.
d. An organized outpatient-based facility for the care and treatment of
unscheduled patient who present for immediate medical attention. The facility
must be available 24 hours a day.

12. Lucus, a three-year-old new patient is seen for a well-child examination. The
doctor documents an age appropriate history, examination, anticipatory
guidelines, risk factor reduction intervention, and indicates Lucus’ immunizations
are up to date. How would you report this service?
a. 99392
b. 99213-25, 99385
c. 99203
d. 99382
13. 80-year-old patient is returning to the gynecologist’s office for pessory
cleaning. Patient offers no complaints. The nurse removes and cleans the pessory,
vagina is swabbed with betadine, and pessory replaced. For F/U in 4 months.
What CPT® and ICD-10 CM should be used for this service?

A. 99201, V45.59 B. 99211,V52.8 C. 99202,T83.69XA D. 99212,V53.99

14. Patient was in the ER complaining of constipation with nausea and vomiting
when taking Zovirax for his herpes zoster and Percocet for pain. His primary care
physician came to the ER and admitted him to the hospital for intravenous
therapy and management of this problem. Time taken for this service is about 59
minutes.His physician documented a medical decision making of moderate
complexity. Which E/M service is reported?

A. 99285 B. 99284 C. 99221 D. 99222

15. 20-day-old infant was seen in the ER by the neonatologist admitting the baby
to NICU for cyanosis and rapid breathing. The neonatologist performed
intubation, ventilation management and a complete echocardiogram in the NICU
and provided a report for the echocardiography which did indicate congenital
heart disease. Select the correct code(s) for the physician service.

A. 99468-25, 93303-26 B. 99471-25, 31500, 94002, 93303

C. 99460-25, 31500, 94002, 93303 D. 99291-25, 93303

16. A 40 year-old patient is coming to see her primary care physician for
hypertension. Her physician performs moderate medical decision making. After
the exam the patient discusses with her physician that the OBGYN office had just
told her that her Pap smear came back with an abnormal reading and is worried
since her aunt had passed away with cervical cancer. The physician discuss other
screening procedures and treatment if it turns out to be cervical cancer. What
code(s) should be used for this visit?
A. 99214
B. 99204
C. 99213
D. 99205
17. A patient was admitted yesterday to the hospital for possible gallstones. The
following day the physician who admitted the patient performed
a medical decision making of low complexity,time spend for this service is 30mins.
The physician tells her the test results have come back positive for gallstones and
is recommending having a cholecystectomy. What code should be reported for
this evaluation and management service?
A. 99253
B. 99221
C. 99231
D. 99234

18. A patient came in to the ER with wheezing and a rapid heart rate. The ER
physician documents a medical decision of moderate complexity. The patient has
been given three nebulizer treatments. The ER physician has decided to place him
in partial hospital setting for the acute asthma exacerbation. The ER physician will
continue examining the patient and will order additional treatments until the
wheezing subsides. Total time spent for this service was 55mins.Select the
appropriate code(s) for this visit.
A. 99284, 99222
B. 99222
C. 99284
D. 99233

19. Patient is here to follow up on her atrial fibrillation. Her primary care physician
is not in the office. She will be seen by the partner physician that is also in the
same practice. No new problems. Blood pressure is 110/64. Pulse is regular at 72.
Temp is 98.6F Chest is clear. Cardiac normal sinus rhythm. Medical making
decision is straightforward. Time spent for this service is 15mins.Diagnosis: Atrial
fibrillation, currently stable. What CPT® code is reported for this service?
A. 99201
B. 99202
C. 99212
D. 99213
20. Documentation of a new patient in a doctor’s office setting ,document
supports the medical making decision making is of high complexity. The time
taken for this encounter is 72 minutes.Which E/M service supports this
documentation?
A. 99205
B. 99203
C. 99204
D. 99202

21.Two-year-old is brought to the ER by EMS for near drowning. EMS had gotten a
pulse. The ER physician performs endotracheal intubation, blood gas, and a
central venous catheter placement. The ER physician documents a total time of
30 minutes on this critical infant in which the physician already subtracted the
time for the other billable services. Select the E/M service and procedures to
report for the ER physician?
A. 99291-25, 36555, 31500
B. 99291, 36556, 31500, 82803
C. 99285-25, 36556, 31500, 82803
D. 99475, 36556

22. 2-year-old is coming in with his mom to see the pediatrician for fever, sore
throat, and pulling of the ears. A strep culture was taken and came back positive.
A diagnosis was also made of the infant having acute otitis media with effusion.
The medical decision making was of low complexity with the giving of a
prescription and the time taken for this service was 25mins. What CPT codes
should be reported?
A. 99205
B. 99215
C. 99212
D. 99213
23. 42-year-old woman is being discharged today, 2/5/XX. She was admitted to
the hospital 2/2/XX for acute diverticulitis. Refer to dictated notes for a detailed
description of the history, exam, and assessment and treatment protocol. Patient
was also seen in consultation by Dr Z. She was placed on intravenous antibiotics
and has made slow steady progress. Today has no abdominal pain. Labs are
normal and CT of the abdomen and pelvis showed changes consistent with
diverticulitis in the left side of colon. She was given follow up instructions of her
medications, what diet to have and to follow up with PCP in 10 to 14 days or
return if pain resumes. Total time spent with patient 40 minutes. What CPT®
code(s) should be reported?
A. 99233, 99239 B. 99217
C. 99252, 99238 D. 99239

24. 63-year-old man is coming in for a second opinion for his sleep apnea. He has
had it for the past five months. Sleep is disrupted by frequent awakenings and
getting worse due to anxiety and snoring. He feels tired all the time, has some
joint stiffness and night sweats;Prescription was given to help with the anxiety.
What CPT® code should be reported?
A. 99203 B. 99204
C. 99244 D. 99214

25. A 55-year-old established patient is coming in for a pre-op visit; he is getting a

liver transplant due to cirrhosis. The physician performs high complexity MDM.
Patient agrees with his physician’s recommendations and the transplantation will
take place as scheduled. After the evaluation, the patient expresses a number of
concerns and questions for the prospective liver transplant. Physician spends an
additional 30 minutes, excluding the time spent in doing the E/M service, in
counseling and answering questions regarding the surgery and discussing possible
outcomes. What CPT® codes should be reported?
A. 99213, 99354 B. 99214, 99358
C. 99213, 99358 D. 99215, 99417
26. Physician performs a medical review and documentation on an 83-year-old
patient still hospitalized for confusion for the last two days. She is alert and
oriented x 3 today. Reviewing her labs from yesterday, her BNP was elevated
suspecting her confusion is due to congestive heart failure. An echocardiogram is
ordered and treatment will be for congestive heart failure. Patient is not safe to
return home.Time taken for this service is 25minutes. What CPT® code should be
reported?
A. 99231 B. 99221
C. 99218 D. 99232

27. A plastic surgeon is called to the ED at the request of the emergency

department physician to evaluate a patient that arrived with multiple facial
fractures after being in an automobile accident for her opinion on the need for
reconstructive surgery. The plastic surgeon arrives at the ED, obtains. The plastic
surgeon performs moderate medical decision making, including deciding the
patient needs major surgery to repair the injuries. The plastic surgeon schedules
the patient for surgery the next day and documents her full note with findings in
the ED chart.
A. 99284-57 B. 99244
C. 99244-57 D. 99221

28. At the request of the mother’s obstetrician, the physician was called to attend
the birth of an infant being delivered at 29 weeks gestation. During delivery, the
neonate was pale and bradycardic. Suctioning and bag ventilation on this 1000
gram neonate was performed with 100 percent oxygen. Brachycardia worsened;
endotracheal intubation was performed and insertion of an umbilical line for fluid
resuscitation. Later this critically ill neonate was moved from the delivery room
and admitted to the NICU with severe respiratory distress and continued
hypotension. What are the appropriate procedure codes?
A. 99465, 99468 B. 99465, 99464, 99468-25, 31500, 36510-51
C. 99468, 99464 D. 99465, 99468-25, 31500-59, 36510-59
29. 38-year-old female initial visit, just moved from out of state, has neck and
back pain for the last year and is getting worse. Pain is exacerbated when she
drives, bends, or changes positions, and moderately alleviated with ibuprofen.
Positive for aches and weakness in her muscles and tingling and numbness of the
arms and hands, as well as headaches. Prescription was given for muscle relaxer.
The time taken for this encounter is 55 minutes.Select the appropriate CPT® code
for this visit?
A. 99203 B. 99204
C. 99214 D. 99244

30. A four-year-old patient presents with pain in the left forearm following a fall
from a chair. The injury occurred one hour ago. Her mom applied ice to the injury
but it does not appear to help. The ED physician ordered X-ray ,which shows a
fracture of the distal end of the radius as read by the radiologist. The ED physician
performs moderate conscious sedation with ketamine for 30 minutes. The
fracture is reduced and cast applied by an orthopedic surgeon following
consultation with the ED physician. The child was monitored with pulse oxymetry,
cardiac monitor and frequent physician evaluation. The patient was discharged
with a sling and requested to follow up with the orthopedic surgeon. Code the
services performed by the ED physician.
A. 99284, 99151 B. 99284-25, 99151,+99153
C. 99283-25, 99155 D. 99283

31. Dr. X performs a follow-up consultation on certain tests that were not
available in a nursing facility for a 75- year-old-male that was having chest pain.
Today the patient is feeling better after a GI cocktail with Maalox and Xylocaine.
The EKG showed an arrhythmia and the chest X-ray came back normal. He listens
to the patient’s heart and lungs. Dr. X makes the recommendation of repeat
cardiac enzymes and EKG and to have a GI evaluation. The PCP accepts the
recommendations and implements the plan of care. What CPT® code should be
reported for Dr. X?
A. 99241 B. 99232
C. 99308 D. 99251
32. Physician was called to the floor to evaluate a 94-year-old that had sudden
weakness, hypotension, and diaphoresis. Physician found the patient in mild
distress and dyspenic. Her BP 101/60, pulse 85. Her heart was positive for a
systolic murmur. EKG came back with ST elevation V2-V6. Labs were still pending.
She was admitted to CCU for Acute Antero-lateral MI and hypotension. Physician
spent total critical care time of 48 minutes. Select the appropriate CPT® code for
this visit:
A. 99253 B. 99233
C. 99291 D. 99236