FOCUS HEALTHCARE SOLUTIONS

Evaluation and Management Assessment

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. This was the only service rendered. How would you report this
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. 71045, 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 a detailed
examination and 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. 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,
shortness of breath 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. How would you report Dr.
Crampon’s services?

A. 99214 B. 99222 C. 99204, 99222-51 D. 99223

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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 2023 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 Dr.
Nancy’s service?

A. 93793 B. 99213
C. 99214 D. This service 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 a comprehensive history, comprehensive examination, and high complexity decision-making. Dr. Jane visited the
patient on days two and three and documented (each day) an expanded problem focused examination and decision-making
of moderate complexity. On day four, Dr. Jane moved the patient to the medical floor and documented a problem focused
examination and straightforward decision-making. Day five, Dr. Jane discharged the patient to home. The discharge took
over an hour. How would you report the services from day one to day five?

A. 99215, 99232, 99231, 99239 x 2 B. 99221, 99222, 99223, 99238

C. 99285, 99222, 99232, 99231, 99239 D. 99223, 99232, 99232, 99231, 99239

9. Which code range would describe services for a critically ill patient who is 23 days old as an outpatient?

A. 99291–99292 B. 99471–99472 C. 99468–99469 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 comprehensive history, comprehensive examination, and 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. 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.

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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’s immunizations are
up to date. How would you report this service?

A. 99392 B. 99213-25, 99382 C. 99203 D. 99382

13. 80-year-old patient is returning to the gynecologist’s office for pessary cleaning. Patient offers no complaints. The
nurse removes and cleans the pessary, vagina is swabbed with betadine, and pessary replaced. For F/U in 4 months.

A. 99203 B. 99211 C. 99202 D. 99212

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. His physician documented a detailed history, comprehensive examination and 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 patient makes an appointment to see his family physician in his office for a physical examination, required to qualify
for a new life insurance policy. The physician completes a medical history, as required by the Life Insurance Company,
which consists of an abbreviated examination of height, weight, and blood pressure, as well as collection of specimen
samples required for laboratory tests. The physician also completes several forms, provided by the life insurance
company, to certify that the information is complete. How would you report the physician’s service?

A.99455 B. 99450 C. 99456 D. 99213

17.A patient was admitted yesterday to the hospital for possible gallstones. The following day the physician who admitted
the patient performed a detailed history, a detailed exam and a medical decision making of moderate complexity. 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 performed today?

A. 99254 B. 99222 C. 99232 D. 99235

18.A patient came in to the ER with wheezing and a rapid heart rate. The ER physician documents a comprehensive
history, comprehensive exam and medical decision of moderate complexity. The patient has been given three nebulizer
treatments. The ER physician has decided to place him in observation care for the acute asthma exacerbation. The ER
physician will continue examining the patient and will order additional treatments until the wheezing subsides. Select the
appropriate code(s) for this visit.

A. 99284, 99222 B. 99222 C. 99284 D. 99235

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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. Diagnosis:
Atrial fibrillation, currently stable. What CPT® code is reported for this service?

A. 99221 B. 99202 C. 99212 D. 99213

20. Documentation of a new patient in a doctor’s office setting supports one stable acute illness & one lab test ordered and
Prescription was given. Which E/M service supports this documentation?

A. 99203 B. 99204 C. 99213 D. 99213

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

C. 99285-25, 36556, 31500 D. 99475, 36556

22. 2-year-old is coming in with his mom to see the pediatrician for fever, sore throat, hearing difficulty and pulling of
the ears. The physician performs a brief history along with a problem pertinent review of systems. A limited exam was
performed on the ears, nose and throat and respiratory systems. A strep culture was taken and came back positive. A
diagnosis was also made of the infant having acute otitis media with effusion. Physician given prescription for the patient.

A. 99212 B. 99213 C. 99211 D. 99214

23. 42-year-old woman is being discharged today, June 05th 2022. She was admitted to the hospital June 2nd 2022 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 35 minutes. What
CPT® code(s) should be reported for today’s service?

A. 99232, 99239 B. 99232` 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 2 years. 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; all other systems were negative. He is going through a divorce which is causing him anxiety
and had a hernia repair two month ago. Doctor performs a comprehensive exam and two labs and a sleep study test.
Prescription was given to help with the anxiety. What CPT® code should be reported?

A. 99203 B. 99204 C. 99244 D. 99214

25. Jack a 34-year-old patient was seen in cruise ship by Dr. Parameswaran for asthma with exacerbation. Physician
documented Detailed history & exam with Low complexity MDM and total time spent by Dr. Parameswara is 60 minutes
during this encounter. What CPT should be reported for Dr. Parameswaran?

A.99343 B. 99350 C. 99342 D. 99203

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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. Physician documented Low level MDM. What CPT® code
should be reported for today?

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 a history of present illness including an
extended history of present illness; a system review, including constitutional, musculoskeletal, integumentary,
neurologic, and EENMT; and the patient’s social history and past medical history. The plastic surgeon then performs
a physical exam including respiratory, cardiovascular, and an extended examination of the skin and bony structures of
the patient’s face. 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. How would you report for plastic surgeon?

A. 99284-57 B. 99244 C. 99243-57 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
800gram neonate was performed with 100 percent oxygen. Bradycardia 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. All other systems are reviewed and are negative. She has had a partial hysterectomy and is divorced.
Her mother has a history of breast cancer. The physician performs an exam on the following systems: constitutional,
eyes, ENT, respiratory, cardiovascular, gastrointestinal, musculoskeletal, and neurologic. X-rays of the cervical and
lumbar spine were taken. Will be sending her to get a MRI and to start physical therapy. Prescription was given for
muscle relaxer which makes MDM moderate. 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 performs a four
system ROS. The patient lives at home with both parents and attends pre-K classes. The patient has no known drug
allergies. The ED physician performs an extended six system exam. An X-ray is ordered, which shows a fracture of
the distal end of the radius as read by the radiologist. MDM documented by ED physician is Moderate level. 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
oximetry, 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.

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A. 99284, 99151, 99153 B. 99284-25, 99155, 99157
C. 99283-25, 99151, 99157 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. Dr. X performs a problem
focused history. 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 which is a low-level MDM. The PCP accepts the recommendations
and implements the plan of care. What CPT® code should be reported for Dr. X?

A. 99242 B. 99232 C. 99308 D. 99252

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 dyspneic. 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

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