Deck 5: Evaluation and Management

Question 1

Services provided to a patient in order to maintain health and prevent disease are called:

A) Home services
B) Palliative services
C) Preventive services
D) Well services

Answer 1

Preventive services

Question 2

Select the statement that is not true regarding critical care code selection:

A) If less than 30 minutes is documented as time spent with the critically ill patient, code 99291 may not be reported
B) Time spent on the floor but not directly at the bedside is counted as long as it pertains to the critical condition of the patient
C) Time spent outside the unit may be considered in the time documentation
D) Total time spent does not have to be continuous but must be documented

Answer 2

Time spent outside the unit may be considered in the time documentation

Question 3

In the Exam component, organ system element, a detailed exam is made up of _______ body areas and/or organ systems:

A) 4-7
B) 4-6
C) 5-8
D) 5-7

Answer 3

5-7

Question 4

An unrelated E/M service by the same physician during a postoperative period is described by modifier:

A) 57
B) 24
C) 32
D) 25

Question 5

Code range 99291-99292 is used to describe:

A) Critical Care services
B) Emergency Department services
C) Nursing Facility Services
D) Office or Other Outpatient Consultations

Question 6

Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services (99466-99486) include all of the following except:

A) outpatient neonatal care
B) continuing intensive care services
C) transportation services for critical care pediatric patients
D) initial intensive care services

Question 7

The E/M section is often the most difficult for coders to understand and use correctly because:

A) this section is newly developed and unfamiliar to coders
B) conflicting guidelines are provided for this section and its subsections
C) this section is based on applying measurements to the provider's work
D) no guidelines are provided for this section

Question 8

Select the correct steps to determining a code for an E/M service, listed in correct order:

A) determine the patient's chief complaint, identify the place of service, identify the type of service, identify the status of the patient
B) identify the status of the patient, determine the patient's chief complaint, identify the place of service, identify the type of service.
C) identify the place of service, identify the type of service, identify the status of the patient, determine the patient's chief complaint
D) determine the patient's chief complaint, identify the status of the patient, identify the place of service, identify the type of service.

Question 9

In the E/M section, a 2 in the fourth place identifies:

A) a critical care service
B) an emergency service
C) an initial inpatient service
D) a subsequent inpatient service

Question 10

A critical care service is identified by a ____ fourth digit:

A) 8
B) 9
C) 0
D) 2

Question 11

In the E/M section, an 8 in the fourth place identifies:

A) an emergency service
B) a critical care service
C) a consultation service in the hospital
D) a consultation service in the office

Question 12

Location, duration, quality, and severity are all subelements of which element?

A) history of present illness
B) amount and complexity of data
C) number of diagnosis and treatment options
D) organ system

Question 13

Which of the following is not included in the Moderate decision making subelement of the Medical decision making element?

A) moderate risk of complications
B) moderate amount of data reviewed
C) high risk of complications
D) multiple diagnosis and management options

Question 14

A patient who has not received face-to-face services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past three years is a(n):

A) new patient
B) established patient
C) consult
D) existing patient

Question 15

Established patient office visit codes are included in the range:

A) 99202-99205
B) 99401-99405
C) 99311-99315
D) 99211-99215

Question 16

The _______ documentation guidelines are followed for the CPC exam:

A) 1995
B) 1997
C) 1991
D) 1998

Question 17

One who has been formally admitted to a healthcare facility is:

A) outpatient
B) observation status
C) critical care
D) inpatient

Question 18

A consultation service in the hospital is represented by a _____ fourth digit:

A) 8
B) 9
C) 5
D) 4

Question 19

How many key components must be met in order to select a code from the Established Patient 99211-99215 code range?

A) three
B) four
C) two
D) one

Question 20

All of the following are included in CPT critical care codes except:

A) vascular access procedures
B) gastric intubation
C) pulmonary function testing
D) pulse oximetry

Question 21

The Evaluation and Management (E/M) section of the CPT manual contains the codes ranging from:

A) 99202-99499
B) 99101-99999
C) 99101-99499
D) 99202-99999

Question 22

Hospital Observation Services codes describe examinations provided in:

A) an inpatient hospital room
B) the Emergency Room
C) an outpatient, provider's office
D) a designated observation status room in a hospital

Question 23

All of the following are categories included in the E/M section of the CPT manual except:

A) critical care services
B) hospital services
C) office services
D) palliative services

Question 24

How many subelements are needed to achieve an Extended history of present illness?

A) four
B) two
C) one
D) three

Question 25

The description of the illness or injury which precipitated the present encounter is the:

A) review of systems
B) chief complaint
C) past history
D) history of present illness

Question 26

Modifier 32, Mandated services, is used when:

A) Patient presents to the office with a cough and while in the office shows the provider a wart on her foot and the provider removes the wart
B) Surgeon performs appendectomy, and the patient returns to the office during the 90 day global period with abdominal pain that is diagnosed as gallstones
C) Surgeon is asked to see a patient in the ED for severe abdominal pain. He diagnoses the patient with appendicitis and decides to perform an appendectomy that evening.
D) Third-party payer requires a second opinion

Question 27

The E/M section guidelines regarding new and established patients uses the terminology "same practice." Payers consider providers to be in the "same practice" when they use:

A) the same tax ID
B) the same facilities
C) the same Social Security number
D) the same billing company

Question 28

To select the appropriate code from this section:

A) The provider must dictate the appropriate CPT code in the documentation
B) The coder must be able to abstract necessary information from the provider's dictation
C) The coder must be able to accurately compare services provided by several providers
D) The provider must document time, counseling, and coordination of care for each visit

Question 29

All of the following are true about critical illness/injury except:

A) a critical illness impairs one or more vital organ systems
B) a patient must be in a critical care unit to be categorized as having a critical illness
C) a patient can be in a setting other than a critical care unit and be designated as critically ill
D) a critical injury presents a high probability of life-threatening deterioration

Question 30

The descriptive words "gait, range of motion, inspect nails, and digits" are used to describe which subelement?

A) cardiovascular
B) eyes
C) constitutional
D) musculoskeletal

Question 31

A patient is seen by a provider today for 80 minutes. Based on the E/M guideline regarding time as a key factor, how many minutes at a minimum must the provider document spending in face-to-face counseling and coordination of care with the patient?

A) 40 minutes
B) 50 minutes
C) 20 minutes
D) 30 minutes

Question 32

All of the following are components of an E/M service except:

A) nature of presenting problem
B) history
C) vital signs
D) coordination of care

Question 33

It is required that _____ key component(s) are met when selecting a code from 99202-99205:

A) Two
B) Three
C) One
D) Four

Question 34

One who has received face-to-face services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past three years is a(n):

A) referral
B) established patient
C) new patient
D) consult

Question 35

The elements of the History component in E/M code selection are:

A) amount and complexity of data, history of present illness, and number of diagnoses and management options
B) history of present illness, body areas, and past, family, and social history
C) body areas, review of systems, and amount and complexity of data
D) history of present illness, review of systems, and past, family, and social history

Question 36

A series of questions presented to the patient which identify any signs and symptoms or contributing factors relevant to the present encounter is a(n):

A) past, family, and social history
B) examination
C) history of present illness
D) review of systems

Question 37

Subsequent Observation Care (99224-99226) is used for:

A) observation or inpatient care if the patient is admitted and discharged on the same day
B) services provided during observation status after the initial-observation care has occurred
C) the first encounter a physician has with an observation status patient
D) final examination, instructions for post-discharge care, and preparation of discharge forms

Question 38

All of the following are components of an E/M service except:

A) dictation time
B) time
C) medical decision making
D) counseling

Question 39

The key component which includes the number of management options or diagnoses is:

A) history
B) medical decision making
C) coordination of care
D) examination

Question 40

The "three R's" regarding consultations are:

A) refer, render, and report
B) request, render, and report
C) refer, recommend, and report
D) request, refer, and render

Question 41

A patient presents to the provider's office with swelling of the face and hands after beginning an amoxicillin treatment three days ago. The patient has no current known drug allergies; the physician requests in writing that an allergist evaluate the patient, render an opinion, and supply a written report stating the opinion. This is an example of a(n):

A) Expert request
B) Consultation
C) Referral
D) Request of opinion

Question 42

Time can be a key ______ for the codes within the E/M section requiring either two or three key components.

A) issue
B) factor
C) component
D) consideration

Question 43

All of the following are true of Initial Hospital Care (99221-99223) codes except:

A) Time must be documented in order to select a code
B) These codes are used for the attending physician's initial encounter with the inpatient
C) All three key components must be met
D) These may be referred to as the admission versus initial encounter

Question 44

All of the following are categories included in the E/M section of the CPT manual except:

A) emergency services
B) care management services
C) psychiatric services
D) preventive medicine services

Question 45

Code 99450 Basic Life and/or Disability Evaluation Services includes all of the following except:

A) documentation of height, weight, and blood pressure
B) completion of appropriate forms
C) collection of blood sample and urinalysis
D) performance of electrocardiogram

Question 46

In the SOAP note format, the assessment contains which key component in E/M selection:

A) exam
B) medical decision making
C) no key component is located here
D) history of present illness

Question 47

Preventive Services code selection is dependent on all but which of the following:

A) Type of patient
B) Gender of the patient
C) Age of the patient
D) New or established patient

Question 48

Services provided in a 24-hour facility to an unscheduled patient with an immediate concern are provided in:

A) emergency department
B) intensive care unit
C) urgent care facility
D) critical care department

Question 49

A visit that is requested in writing and that involves the rendering of an opinion and the compilation of a written report is:

A) specialty office visit
B) referral
C) transfer or care
D) consultation

Question 50

In the E/M section, a 0 in the fourth place identifies:

A) a subsequent inpatient service
B) an initial inpatient service
C) an established patient service in the office
D) a new patient service in the office

Question 51

One who has not been formally admitted to inpatient status is:

A) inpatient
B) outpatient
C) emergency services
D) inmate status

Question 52

An established patient presents to the outpatient provider's office with a chief complaint of sore throat. Which piece of information represents the first step in determining a code for an E/M service?

A) established patient
B) sore throat
C) provider's office
D) outpatient

Question 53

Codes in this range are reported when services are provided that are outside the normal services provided for the condition or injury of the present encounter:

A) Preventive Services
B) Critical Care Services
C) Home Services
D) Prolonged Services

Question 54

Code 99291 represents this time frame of Critical Care services:

A) the first 30-74 minutes
B) an additional 70 minutes
C) the first 20-60 minutes
D) an additional 30 minutes

Question 55

In the table of risk, the highest level in any one _____________ determines the overall risk:

A) subsection
B) subelement
C) element
D) subcategory

Question 56

Which of the following is not a true statement?

A) No distinction is made between new and established patient for critical care codes
B) No distinction is made between new and established patient in the outpatient and inpatient setting
C) No distinction is made between new and established patient for the emergency department
D) No distinction is made between new and established patient for care management codes

Question 57

Stacy is being seen by Dr. Randall for the first time for tingling in her wrist and lower arm. Dr. Randall is part of a multi-physician orthopedic practice. Stacy saw Dr. Furman, another orthopedist in the practice, one year ago for treatment of a broken pinkie finger. Stacy will be a(n) _______ for Dr. Randall:

A) referral
B) new patient
C) established patient
D) consult

Question 58

Codes 99202-99215 contain:

A) inpatient services
B) screening services
C) outpatient services
D) counseling services

Question 59

Code range 99341-99350 represents:

A) Critical Care Services
B) Prolonged Services
C) Home Services
D) Nursing Facility Discharge Services

Question 60

A subsequent inpatient service is identified by a _____ fourth digit:

A) 2
B) 3
C) 4
D) 5

Question 61

PFSH stands for:

A) past, former, and surgical history
B) past, family, and social history
C) personal, family, and surgical history
D) personal, family, and social history

Question 62

Select the true statement regarding consultations:

A) Inpatient consultations do not distinguish between new and established patients; office or other outpatient consultations distinguish between new and established patients
B) Inpatient consultations distinguish between new and established patients; office or other outpatient consultations do not distinguish between new and established patients
C) Inpatient consultations require that two of the three key components be met for the level of service; office or other outpatient consultations require that all three key components must be met for the level of service
D) Both inpatient and office or other outpatient consultations require that all three key components must be met for the level of service

Question 63

A patient presents with worsening lower back pain after receiving an epidural injection intended to provide relief just one week ago. Upon examination, the provider determines the patient is a candidate for laminectomy at the L5-S1 facet. The provider discusses the procedure, including preoperative instructions and performs a complete physical examination to clear the patient for surgery. Which modifier will be appended to this E/M service?

A) 24
B) 57
C) 32
D) 25

Question 64

To obtain a level 99222 or 99223 code, a(n) __________ exam must have been performed and documented.

A) comprehensive
B) detailed
C) expanded problem-focused
D) problem-focused

Question 65

If a patient is admitted into observation status and then is admitted to inpatient status on the same day, the coder may:

A) assign an Initial Observation Care code and an Initial Hospital Care code
B) assign either an Initial Observation Care code or an Initial Hospital Care code depending on the amount of time the provider spent with the patient in each status
C) assign only an Initial Observation Care code
D) assign only an Initial Hospital Care code

Question 66

The E/M section is used to tell the story of the services provided to the patient in a(n):

A) Both outpatient setting and inpatient setting
B) laboratory encounter
C) outpatient setting
D) inpatient setting

Question 67

Code 99217 describes:

A) Initial Observation Care
B) Observation or Inpatient Care Services (Including Admission and Discharge Services)
C) Observation Care Discharge Services
D) Subsequent Observation Care

Question 68

Gerald fell 6 feet from a ladder while running wire at work today. He presents to the provider's office with complaints of low back pain and left knee pain. He arrives with a paper copy of the notes from a visit with his primary care physician about these problems. His employer requested Gerald receive a second opinion from another provider to confirm the diagnosis. What E/M modifier would be appended to the code for today's service?

A) 25
B) 24
C) 32
D) 57

Question 69

Past, family, and social history (PFSH) encompasses which of the following:

A) family's marital status and allergies
B) spouse's risk factors, marital status, allergies, and family illnesses
C) patient's past surgeries, allergies, and family illnesses
D) family's past surgeries, allergies, and illnesses

Question 70

The major factor for using the consultation range of codes is the ____________ of the service:

A) extent
B) intent
C) length
D) significance

Question 71

The actual time the provider or qualified healthcare professional spends with the patient and/or family in the office or outpatient setting is called:

A) personal, family, and social history
B) review of systems
C) face-to-face time
D) counseling time

Question 72

The code range 99455-99456 Work-Related or Medical Disability Evaluation Services has a designation indicating:

A) whether the service was mandated by the employer
B) new or established patient
C) treatment plan or consultative service
D) whether the examination is performed by the treating or nontreating physician

Question 73

An established patient service in the office is indicated by a ______ fourth place digit:

A) 1
B) 2
C) 3
D) 4

Question 74

The three key components used to select an appropriate E/M code are:

A) History, medical decision making, and time
B) History, examination, and medical decision making
C) Counseling, history, and examination
D) Counseling, coordination of care, and time

Question 75

If a patient is discharged from inpatient care on the same day as a nursing facility admit, the coder may select:

A) an Initial Nursing Facility Care code and a hospital discharge code
B) a hospital discharge code and a Subsequent Nursing Facility Care code
C) an Initial Nursing Facility Care code only
D) an observation status discharge code and an Initial Nursing Facility Care code

Question 76

Patient Sally by Dr. Lane in the office on January 11. Upon examination, Dr. Lane recommended that Sally be transferred to the hospital for observation of her increasing heart palpitations. Dr. Lane followed up with Sally later that day in the observation room to monitor her progress. Select the appropriate code ranges and sequencing to describe these services:

A) Inpatient Consultations (99251-99255), followed by Initial Observation Care (99218-99220)
B) Initial Observation Care (99218-99220), followed by (99241-99245) Office or Other Outpatient Consultations
C) Initial Observation Care (99218-99220), followed by Established Patients Office or Other Outpatient Services (99211-99215)
D) Initial Observation Care (99218-99220)

Question 77

The transferring of care for the patient's present illness is:

A) referral
B) consultation
C) routine office visit
D) specialty consultation

Question 78

In the hospital, face-to-face time is calculated by:

A) the amount of time the physician spends on the floor or unit that is related to the care given to the patient
B) the amount of time the physician spends speaking with the patient and/or family in the hospital room
C) the amount of time the nurse and provider spend speaking about the patient's case
D) the amount of time the physician spends in that hospital on the date of service

Question 79

In the E/M section, a 4 in the fourth place identifies:

A) an emergency service
B) a critical care service
C) a consultation service in the hospital
D) a consultation service in the office

Question 80

Which E/M modifier is appropriate to use with this scenario: A patient presents to the orthopedist's office with a complaint of severely sore knee while in the post-operative period for a carpal tunnel decompression performed by the same provider.

A) 25
B) 32
C) 24
D) 57