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 a detailed examination and decision-making of
moderate complexity with time duration of 30 minutes. 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, 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 a
comprehensive history, comprehensive examination, and decision-making of moderate complexity. 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 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. 99213, 99232, 99231, 99239 x 2
b. 99221, 99222, 99223, 99238
c. 99231, 99232, 99355, 99217
d. 99223, 99232, 99232, 99231, 99239

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 comprehensive history,
comprehensive examination, and decision-making of high complexity, time duration of 60 min. 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.
12. Lucus, a three-year-old new patient is seen for a well-child examination. The doctor documents
lowMDM for an average of 25 min and then continued with wellness visit, 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, 99382
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 should be used for this service?

A. 99201 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

16. A 40 year-old patient is coming to see her primary care physician for hypertension. Her physician
performs an expanded problem focused exam and low medical decision making with time 35 minutes.
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 spends an extra 45 minutes face-to-face time discussing with her the
awareness, other screening procedures and treatment if it turns out to be cervical cancer. What code(s)
should be used for this visit?
A. 99215
B. 99213, 99354
C. 99213
D. 99213, 99403
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 low 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?
A. 99253
B. 99221
C. 99233
D. 99234

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, 99219
B. 99219
C. 99284
D. 99235

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, with time of 10 min. 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 supports the History in four elements for
an extended history of present illness (HPI), three elements for an extended review of systems (ROS)
and three elements for a complete Past, Family, Social History (PFSH) . There is an extended examination
of six body areas and organ systems. The medical making decision making is of moderate complexity
with time of 54 minutes. Which E/M service supports this documentation?
A. 99205
B. 99204
C. 99203
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. 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.
The medical decision making was of moderate complexity with the giving of a prescription, time of 30
minutes. What CPT® and ICD-9-CM codes should be reported?
A. 99211
B. 99213
C. 99212
D. 99214

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; 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 orders labs and a sleep study test with Moderate MDM and time-
45 minutes. 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 an expanded problem focused history, detailed examination, and high
MDM with 40 minutes. 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 55 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. 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 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.
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 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. 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 wherein MDM is moderate, time-45 min .
Prescription was given for muscle relaxer. 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. 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.
A. 99284, 99151 B. 99284-25, 99155
C. 99283-25, 99151 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. 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