Deck 23: Coding for Evaluation and Management E&M, Anesthesia, and Surgery Section

Question 1

CPT codes that contain a set of temporary codes used for emerging technology, services, and procedures can be found in which of the following sections of the CPT manual?

A) Appendix A
B) Appendix D
C) Category II
D) Category III

Answer 1

Category III

Question 2

A 19-year-old male was jumping off the roof of his home onto a trampoline. After several successful jumps, he was careless and misjudged the distance on his next jump. He missed the trampoline and landed on the ground, injuring his right foot. The next day the teen was taken to his physician's office. The physician ordered a three-view x-ray of the right foot. The physician performed a medically appropriate history and examination, and the medical decision making was of moderate complexity. After determining that the teen has suffered a displaced fracture of the first metatarsal of the right foot, the physician refers the teen to an orthopaedic surgeon. Select the appropriate code(s) for the family physician:

A) 99214, S92.311A
B) 99215, S92.253A
C) 99204, S92.819A
D) 99205, S92.316A

Answer 2

99214, S92.311A

Question 3

Choose the appropriate CPT code for a care-plan oversight service performed by a physician for 45 minutes on a home health patient.

A) 99375
B) 99326
C) 99358
D) 99379

Answer 3

99375

Question 4

Mary was admitted to the hospital with congestive heart failure by her primary care physician, and cardiology was consulted on the day of admission. On the second day, the cardiologist made hospital rounds and stopped by to see Mary. An expanded problem-focused interval history was obtained, and an expanded problem-focused examination was performed. Mary is showing some improvement with IV therapy. Select the appropriate code for Mary's encounter with the cardiologist today:

A) 99233
B) 99232
C) 99253
D) 99213

Question 5

The patient is a weight lifter who was training with heavy weights. While doing bicep curls, the patient experienced pain in the left forearm. A hematoma occurred, and he sought immediate medical treatment. He was diagnosed with a ruptured vein in his forearm. General anesthesia was administered in order to suture the vein. Which of the following codes is the appropriate code for reporting this service?

A) 01840
B) 01850
C) 01842
D) 01852

Question 6

A patient was admitted into the observation unit of the hospital at 8 a.m. after presenting with pain in the lower back. After reviewing the test results of the lab work and discussing the ultrasound results with the radiologist, the physician diagnosed kidney stones. The physician performed a comprehensive history and comprehensive examination of the patient. The physician approved a plan of treatment and discharged the patient at 1:30 p.m. the same day. Choose the appropriate CPT code(s):

A) 99235
B) 99221
C) 99236
D) 99218, 99217

Question 7

P1 and P6 are examples of which of the following?

A) Anesthesia time-reporting format
B) Anesthesia physical-status modifiers
C) Indications of multiple procedures
D) Anesthesia qualifying circumstances

Question 8

A perineoplasty, nonobstetrical, was performed on a 37-year-old female patient. Which range of CPT codes is appropriate for this procedure?

A) 56800-56810
B) 56405-58999
C) 50010-53899
D) 59000-59899

Question 9

Which of the following statements best describes when time becomes a factor in determining the appropriate non-office evaluation and management code?

A) Time is never a factor in determining the appropriate code.
B) Time is a factor when counselling and/or coordination of care represents more than 50 percent of the patient-provider encounter and is documented in the medical record.
C) Time is always one of the key components in determining the level of the code.
D) The physician needs to dictate only that he or she spent extra time with the patient.

Question 10

A screening mammogram is performed unilaterally. Choose the appropriate code for this service:

A) 77067 with the charge reduced
B) 77067
C) 77067-52
D) 77065

Question 11

Dr. G was asked to provide a cardiology consultation in the emergency department for a patient who was experiencing atrial fibrillation. Dr. G determined that the patient needed to have a dual-chamber pacemaker inserted, and he scheduled the patient to have this procedure on the following morning. To correctly code the outpatient consultation visit in the ED, which of the following modifiers needs to be appended?

A) Modifier 24
B) Modifier 58
C) Modifier 51
D) Modifier 57

Question 12

The patient presented today with swelling and pain in the right knee. The patient suffers from primary osteoarthritis. Following a medically appropriate history and examination, the physician aspirated the joint and gave the patient an injection of steroid medication. Select the appropriate codes for today's visit:

A) 99213, 20610, M12.9
B) 99213, 20610, M17.11
C) 99213-25, 20610, M12.9
D) 99213-25, 20610, M17.11

Question 13

An examination of joints using a scope is an:

A) Arthroscopy
B) Arthrodesis
C) Arthrography
D) Arthroplasty

Question 14

Peter Dixon was found to have an esophageal stricture, so he consented to esophageal dilation under general anesthesia to reduce this stricture. Select the appropriate anesthesia code(s):

A) 00500, P1
B) 00500, P4
C) 00100
D) 00500, 99140

Question 15

A donor was brought to the operating room and placed under general anesthesia for harvesting of bone marrow. Select the correct code(s) to report the anesthesia services:

A) 01112, P1, Z52.001
B) 01112, P1, Z52.3
C) 01120, P1, Z52.3
D) 01120, P1, Z52.001

Question 16

A 92-year-old woman is confined to a wheelchair and cannot live by herself. She resides in a residential facility for the elderly. Once every month, the facility has a physician come to the facility to examine and monitor the health of the residents. The physician makes recommendations to the facility and/or family members on the course of care to be given to the woman each month to maintain her health. At today's encounter the physician performs a problem-focused examination and interval history. The decision making is straightforward. Choose the appropriate CPT code:

A) 99328
B) 99335
C) 99334
D) 99324

Question 17

Which one of the following procedures is completed without incision and is considered noninvasive in nature?

A) Closed procedure
B) Percutaneous procedure
C) Open procedure
D) Endoscopic procedure

Question 18

Jonathan is a 12-year-old whose mother took him to his pediatrician for his annual exam. While examining him, his pediatrician discovered that he had an inguinal hernia and performed a problem-focused history, a problem-focused exam, and straightforward medical decision making. The pediatrician is referring Jonathan to a surgeon for the hernia repair, and Jonathan is to return to his pediatrician in 1 year. Choose the appropriate code(s) for Jonathan's visit:

A) 99394
B) 99384, 99212-25
C) 99212
D) 99394, 99212-25

Question 19

Which of the following is not an element of a history component for evaluation and management coding?

A) Review of systems
B) Social history
C) Chief complaint
D) Number of diagnoses and management options

Question 20

Which of the following is a type of medication used solely to relieve pain?

A) Corticosteroid
B) Analgesic
C) Muscle relaxant
D) NSAID

Question 21

What anesthesia codes would be assigned for harvesting organ(s) from a brain-dead person?

A) 00580, P6
B) 01990
C) 01990, P6
D) 01999

Question 22

Which of the following is the type of anesthesia that makes a large portion of the body numb?

A) Local anesthesia
B) Regional anesthesia
C) General anesthesia
D) Moderate sedation

Question 23

Code the appropriate anesthesia service for Fowler-Stephens orchiopexy. The patient is a normal, healthy, 30-year-old male.

A) 00924
B) 00930, P1
C) 00928
D) 00926

Question 24

A physician who is part of a medical group practice saw a patient today who had not been treated by the practice for 7 years. The patient presented with a persistent cough and some congestion. The physician performed a medically appropriate history and examination. The patient is diabetic, which is controlled with diet and medication. The physician ordered lab work and a CXR. The physician prescribed medication for the cough and congestion and gave the patient a new prescription for his diabetic medication. The patient was asked to return in 1 week. Provider used low level of decision making. Choose the appropriate evaluation and management code for today's encounter:

A) 99203
B) 99213
C) 99204
D) 99214

Question 25

Jonathan is a 12-year-old whose mother took him to his pediatrician for his annual exam. While examining him, his pediatrician discovered that he had an inguinal hernia and performed a problem-focused history, a problem-focused exam, and straightforward medical decision making. The pediatrician is referring Jonathan to a surgeon for the hernia repair, and Jonathan is to return to his pediatrician in 1 year. Choose the appropriate code(s) for Jonathan's visit:

A) 99384, 99212-25
B) 99394, 99212-25
C) 99394
D) 99212

Question 26

Which of the following statements best describes when time becomes a factor in determining the appropriate non-office evaluation and management code?

A) Time is always one of the key components in determining the level of the code.
B) Time is a factor when counselling and/or coordination of care represents more than 50 percent of the patient-provider encounter and is documented in the medical record.
C) Time is never a factor in determining the appropriate code.
D) The physician needs to dictate only that he or she spent extra time with the patient.

Question 27

Which one of the following procedures is completed without incision and is considered noninvasive in nature?

A) Open procedure
B) Percutaneous procedure
C) Closed procedure
D) Endoscopic procedure

Question 28

The patient is a weight lifter who was training with heavy weights. While doing bicep curls, the patient experienced pain in the left forearm. A hematoma occurred, and he sought immediate medical treatment. He was diagnosed with a ruptured vein in his forearm. General anesthesia was administered in order to suture the vein. Which of the following codes is the appropriate code for reporting this service?

A) 01840
B) 01842
C) 01850
D) 01852

Question 29

A perineoplasty, nonobstetrical, was performed on a 37-year-old female patient. Which range of CPT codes is appropriate for this procedure?

A) 56405-58999
B) 56800-56810
C) 50010-53899
D) 59000-59899

Question 30

Peter Dixon was found to have an esophageal stricture, so he consented to esophageal dilation under general anesthesia to reduce this stricture. Select the appropriate anesthesia code(s):

A) 00500, P1
B) 00100
C) 00500, 99140
D) 00500, P4

Question 31

A physician who is part of a medical group practice saw a patient today who had not been treated by the practice for 7 years. The patient presented with a persistent cough and some congestion. The physician performed a medically appropriate history and examination. The patient is diabetic, which is controlled with diet and medication. The physician ordered lab work and a CXR. The physician prescribed medication for the cough and congestion and gave the patient a new prescription for his diabetic medication. The patient was asked to return in 1 week. Provider used low level of decision making. Choose the appropriate evaluation and management code for today's encounter:

A) 99204
B) 99203
C) 99213
D) 99214

Question 32

Dr. G was asked to provide a cardiology consultation in the emergency department for a patient who was experiencing atrial fibrillation. Dr. G determined that the patient needed to have a dual-chamber pacemaker inserted, and he scheduled the patient to have this procedure on the following morning. To correctly code the outpatient consultation visit in the ED, which of the following modifiers needs to be appended?

A) Modifier 57
B) Modifier 58
C) Modifier 24
D) Modifier 51

Question 33

The patient presented today with swelling and pain in the right knee. The patient suffers from primary osteoarthritis. Following a medically appropriate history and examination, the physician aspirated the joint and gave the patient an injection of steroid medication. Select the appropriate codes for today's visit:

A) 99213-25, 20610, M12.9
B) 99213-25, 20610, M17.11
C) 99213, 20610, M12.9
D) 99213, 20610, M17.11

Question 34

Choose the appropriate CPT code for a care-plan oversight service performed by a physician for 45 minutes on a home health patient.

A) 99326
B) 99379
C) 99358
D) 99375

Question 35

An examination of joints using a scope is an:

A) Arthrography
B) Arthroplasty
C) Arthrodesis
D) Arthroscopy

Question 36

CPT codes that contain a set of temporary codes used for emerging technology, services, and procedures can be found in which of the following sections of the CPT manual?

A) Category II
B) Category III
C) Appendix A
D) Appendix D

Question 37

A donor was brought to the operating room and placed under general anesthesia for harvesting of bone marrow. Select the correct code(s) to report the anesthesia services:

A) 01120, P1, Z52.3
B) 01120, P1, Z52.001
C) 01112, P1, Z52.3
D) 01112, P1, Z52.001

Question 38

A screening mammogram is performed unilaterally. Choose the appropriate code for this service:

A) 77065
B) 77067
C) 77067-52
D) 77067 with the charge reduced

Question 39

A 19-year-old male was jumping off the roof of his home onto a trampoline. After several successful jumps, he was careless and misjudged the distance on his next jump. He missed the trampoline and landed on the ground, injuring his right foot. The next day the teen was taken to his physician's office. The physician ordered a three-view x-ray of the right foot. The physician performed a medically appropriate history and examination, and the medical decision making was of moderate complexity. After determining that the teen has suffered a displaced fracture of the first metatarsal of the right foot, the physician refers the teen to an orthopaedic surgeon. Select the appropriate code(s) for the family physician:

A) 99205, S92.316A
B) 99204, S92.819A
C) 99215, S92.253A
D) 99214, S92.311A

Question 40

A patient was admitted into the observation unit of the hospital at 8 a.m. after presenting with pain in the lower back. After reviewing the test results of the lab work and discussing the ultrasound results with the radiologist, the physician diagnosed kidney stones. The physician performed a comprehensive history and comprehensive examination of the patient. The physician approved a plan of treatment and discharged the patient at 1:30 p.m. the same day. Choose the appropriate CPT code(s):

A) 99221
B) 99235
C) 99218, 99217
D) 99236

Question 41

Which of the following is a type of medication used solely to relieve pain?

A) Corticosteroid
B) Muscle relaxant
C) NSAID
D) Analgesic

Question 42

Mary was admitted to the hospital with congestive heart failure by her primary care physician, and cardiology was consulted on the day of admission. On the second day, the cardiologist made hospital rounds and stopped by to see Mary. An expanded problem-focused interval history was obtained, and an expanded problem-focused examination was performed. Mary is showing some improvement with IV therapy. Select the appropriate code for Mary's encounter with the cardiologist today:

A) 99253
B) 99232
C) 99213
D) 99233

Question 43

Code the appropriate anesthesia service for Fowler-Stephens orchiopexy. The patient is a normal, healthy, 30-year-old male.

A) 00924
B) 00930, P1
C) 00926
D) 00928

Question 44

A 92-year-old woman is confined to a wheelchair and cannot live by herself. She resides in a residential facility for the elderly. Once every month, the facility has a physician come to the facility to examine and monitor the health of the residents. The physician makes recommendations to the facility and/or family members on the course of care to be given to the woman each month to maintain her health. At today's encounter the physician performs a problem-focused examination and interval history. The decision making is straightforward. Choose the appropriate CPT code:

A) 99328
B) 99324
C) 99335
D) 99334

Question 45

Which modifier would be assigned to an anterior packing of both nares for a nose bleed?

A) Modifier 59
B) Modifier 22
C) Modifier 51
D) Modifier 50

Question 46

Which of the following is not an element of a history component for evaluation and management coding?

A) Chief complaint
B) Number of diagnoses and management options
C) Review of systems
D) Social history

Question 47

Which of the following is a type of medication used solely to relieve pain?

A) Corticosteroid
B) Muscle relaxant
C) NSAID
D) Analgesic

Question 48

The patient presented today with swelling and pain in the right knee. The patient suffers from primary osteoarthritis. Following an expanded problem-focused history and expanded problem-focused examination, the physician aspirated the joint and gave the patient an injection of steroid medication. Select the appropriate codes for today's visit:

A) 99213, 20610, M12.9
B) 99213-25, 20610, M17.11
C) 99213-25, 20610, M12.9
D) 99213, 20610, M17.11

Question 49

Mary was admitted to the hospital with congestive heart failure by her primary care physician, and cardiology was consulted on the day of admission. On the second day, the cardiologist made hospital rounds and stopped by to see Mary. An expanded problem-focused interval history was obtained, and an expanded problem-focused examination was performed. Mary is showing some improvement with IV therapy. Select the appropriate code for Mary's encounter with the cardiologist today:

A) 99213
B) 99232
C) 99253
D) 99233

Question 50

Jonathan is a 12-year-old whose mother took him to his pediatrician for his annual exam. While examining him, his pediatrician discovered that he had an inguinal hernia and performed a problem-focused history, a problem-focused exam, and straightforward medical decision making. The pediatrician is referring Jonathan to a surgeon for the hernia repair, and Jonathan is to return to his pediatrician in 1 year. Choose the appropriate code(s) for Jonathan's visit:

A) 99384, 99212-25
B) 99212
C) 99394
D) 99394, 99212-25

Question 51

The patient is a weight lifter who was training with heavy weights. While doing bicep curls, the patient experienced pain in the left forearm. A hematoma occurred, and he sought immediate medical treatment. He was diagnosed with a ruptured vein in his forearm. General anesthesia was administered in order to suture the vein. Which of the following codes is the appropriate code for reporting this service?

A) 01840
B) 01850
C) 01842
D) 01852

Question 52

Choose the appropriate CPT code for a care-plan oversight service performed by a physician for 45 minutes:

A) 99326
B) 99379
C) 99375
D) 99358

Question 53

Dr. G was asked to provide a cardiology consultation in the emergency department for a patient who was experiencing atrial fibrillation. Dr. G determined that the patient needed to have a dual-chamber pacemaker inserted, and he scheduled the patient to have this procedure on the following morning. To correctly code the outpatient consultation visit in the ED, which of the following modifiers needs to be appended?

A) Modifier 24
B) Modifier 57
C) Modifier 51
D) Modifier 58

Question 54

Which modifier would be assigned to an anterior packing of both nares for a nose bleed?

A) Modifier 51
B) Modifier 59
C) Modifier 22
D) Modifier 50

Question 55

What anesthesia codes would be assigned for harvesting organ(s) from a brain-dead person?

A) 01999
B) 01990
C) 00580, P6
D) 01990, P6

Question 56

A perineoplasty, nonobstetrical, was performed on a 37-year-old female patient. Which range of CPT codes is appropriate for this procedure?

A) 56405-58999
B) 56800-56810
C) 59000-59899
D) 50010-53899

Question 57

Which one of the following procedures is completed without incision and is considered noninvasive in nature?

A) Endoscopic procedure
B) Open procedure
C) Closed procedure
D) Percutaneous procedure

Question 58

Which of the following is not an element of a history component for evaluation and management coding?

A) Number of diagnoses and management options
B) Chief complaint
C) Review of systems
D) Social history

Question 59

A physician who is part of a medical group practice saw a patient today who had not been treated by the practice for 7 years. The patient presented with a persistent cough and some congestion. The physician performed a comprehensive history and detailed exam. The patient is diabetic, which is controlled with diet and medication. The physician ordered lab work and a CXR. The physician prescribed medication for the cough and congestion and gave the patient a new prescription for his diabetic medication. The patient was asked to return in 1 week. Choose the appropriate evaluation and management code for today's encounter:

A) 99213
B) 99203
C) 99214
D) 99204

Question 60

A 19-year-old male was jumping off the roof of his home onto a trampoline. After several successful jumps, he was careless and misjudged the distance on his next jump. He missed the trampoline and landed on the ground, injuring his right foot. The next day the teen was taken to his physician's office. The physician ordered a three-view x-ray of the right foot. The physician performed a detailed history and a detailed examination, and the medical decision making was of moderate complexity. After determining that the teen has suffered a displaced fracture of the first metatarsal of the right foot, the physician refers the teen to an orthopedic surgeon. Select the appropriate code(s) for the family physician:

A) 99214, S92.311A
B) 99204, S92.819A
C) 99215, S92.253A
D) 99205, S92.316A

Question 61

Code the appropriate anesthesia service for Fowler-Stephens orchiopexy. The patient is a normal, healthy, 30-year-old male.

A) 00924
B) 00926
C) 00928
D) 00930, P1

Question 62

A donor was brought to the operating room and placed under general anesthesia for harvesting of bone marrow. Select the correct code(s) to report the anesthesia services:

A) 01112, P1, Z52.001
B) 01120, P1, Z52.3
C) 01120, P1, Z52.001
D) 01112, P1, Z52.3

Question 63

A 92-year-old woman is confined to a wheelchair and cannot live by herself. She resides in a residential facility for the elderly. Once every month, the facility has a physician come to the facility to examine and monitor the health of the residents. The physician makes recommendations to the facility and/or family members on the course of care to be given to the woman each month to maintain her health. At today's encounter the physician performs a problem-focused examination and interval history. The decision making is straightforward. Choose the appropriate CPT code:

A) 99335
B) 99324
C) 99334
D) 99328

Question 64

An examination of joints using a scope is an:

A) Arthrodesis
B) Arthroplasty
C) Arthroscopy
D) Arthrography

Question 65

CPT codes that contain a set of temporary codes used for emerging technology, services, and procedures can be found in which of the following sections of the CPT manual?

A) Category III
B) Category II
C) Appendix D
D) Appendix A

Question 66

P1 and P6 are examples of which of the following?

A) Indications of multiple procedures
B) Anesthesia time-reporting format
C) Anesthesia qualifying circumstances
D) Anesthesia physical-status modifiers

Question 67

Which of the following is the type of anesthesia that makes a large portion of the body numb?

A) Local anesthesia
B) Regional anesthesia
C) Moderate sedation
D) General anesthesia

Question 68

A screening mammogram is performed unilaterally. Choose the appropriate code for this service:

A) 77067 with the charge reduced
B) 77067
C) 77065
D) 77067-52

Question 69

A patient was admitted into the observation unit of the hospital at 8 a.m. after presenting with pain in the lower back. After reviewing the test results of the lab work and discussing the ultrasound results with the radiologist, the physician diagnosed kidney stones. The physician performed a comprehensive history and comprehensive examination of the patient. The physician approved a plan of treatment and discharged the patient at 1:30 p.m. the same day. Choose the appropriate CPT code(s):

A) 99221
B) 99236
C) 99235
D) 99218, 99217

Question 70

Peter Dixon was found to have an esophageal stricture, so he consented to esophageal dilation under general anesthesia to reduce this stricture. Select the appropriate anesthesia code(s):

A) 00100
B) 00500, P4
C) 00500, 99140
D) 00500, P1

Question 71

P1 and P6 are examples of which of the following?

A) Anesthesia qualifying circumstances
B) Indications of multiple procedures
C) Anesthesia time-reporting format
D) Anesthesia physical-status modifiers

Question 72

A 19-year-old male was jumping off the roof of his home onto a trampoline. After several successful jumps, he was careless and misjudged the distance on his next jump. He missed the trampoline and landed on the ground, injuring his right foot. The next day the teen was taken to his physician's office. The physician ordered a three-view x-ray of the right foot. The physician performed a detailed history and a detailed examination, and the medical decision making was of moderate complexity. After determining that the teen has suffered a displaced fracture of the first metatarsal of the right foot, the physician refers the teen to an orthopedic surgeon. Select the appropriate code(s) for the family physician:

A) 99214, S92.311A
B) 99215, S92.253A
C) 99205, S92.316A
D) 99204, S92.819A

Question 73

A 92-year-old woman is confined to a wheelchair and cannot live by herself. She resides in a residential facility for the elderly. Once every month, the facility has a physician come to the facility to examine and monitor the health of the residents. The physician makes recommendations to the facility and/or family members on the course of care to be given to the woman each month to maintain her health. At today's encounter the physician performs a problem-focused examination and interval history. The decision making is straightforward. Choose the appropriate CPT code:

A) 99334
B) 99324
C) 99328
D) 99335

Question 74

A screening mammogram is performed unilaterally. Choose the appropriate code for this service:

A) 77067-52
B) 77067 with the charge reduced
C) 77065
D) 77067

Question 75

A patient was admitted into the observation unit of the hospital at 8 a.m. after presenting with pain in the lower back. After reviewing the test results of the lab work and discussing the ultrasound results with the radiologist, the physician diagnosed kidney stones. The physician performed a comprehensive history and comprehensive examination of the patient. The physician approved a plan of treatment and discharged the patient at 1:30 p.m. the same day. Choose the appropriate CPT code(s):

A) 99236
B) 99218, 99217
C) 99235
D) 99221

Question 76

CPT codes that contain a set of temporary codes used for emerging technology, services, and procedures can be found in which of the following sections of the CPT manual?

A) Appendix D
B) Appendix A
C) Category II
D) Category III

Question 77

Choose the appropriate CPT code for a care-plan oversight service performed by a physician for 45 minutes:

A) 99358
B) 99375
C) 99326
D) 99380

Question 78

The patient presented today with swelling and pain in the right knee. The patient suffers from primary osteoarthritis. Following an expanded problem-focused history and expanded problem-focused examination, the physician aspirated the joint and gave the patient an injection of steroid medication. Select the appropriate codes for today's visit:

A) 99213-25, 20610, M12.9
B) 99213-25, 20610, M17.11
C) 99213, 20610, M12.9
D) 99213, 20610, M17.11

Question 79

Which of the following is not an element of a history component for evaluation and management coding?

A) Social history
B) Review of systems
C) Chief complaint
D) Number of diagnoses and management options

Question 80

A donor was brought to the operating room and placed under general anesthesia for harvesting of bone marrow. Select the correct code(s) to report the anesthesia services:

A) 01120, P1, Z52.001
B) 01112, P1, Z52.001
C) 01112, P1, Z52.3
D) 01120, P1, Z52.3