Evaluation and Management Coding with CPT: Master the Basics

Question 1

Which modifier is used to indicate that a procedure was performed on a different day from the E/M service?

Accepted Answer

-59

Answer

-62

Answer

-91

Answer

-92

Question 2

When performing an established patient office visit, which of the following is considered a **detailed history**?

Accepted Answer

Comprehensive review of systems covering multiple organ systems

Answer

Collection of subjective information and past medical history

Answer

Review of current medications and allergies

Answer

Social history and family history

Question 3

Which of the following physical exam elements is considered comprehensive?

Accepted Answer

All body systems

Answer

Heart and lungs

Question 4

What is the significance of the phrase 'ordered by another physician' in the documentation of a consultation service?

Accepted Answer

It indicates that the patient was referred by another physician.

Answer

It implies that the consulting physician is not responsible for patient care.

Question 5

Which of the following procedures is considered a minor surgical procedure?

Accepted Answer

Skin biopsy

Answer

Appendectomy

Question 6

What is the key difference between a level I and level II office visit?

Accepted Answer

Level II visit includes more detailed history taking and physical exam.

Answer

Level I visit includes more complex medical decision-making.

Question 7

Which of the following is NOT a type of E/M service?

Accepted Answer

Wellness exam

Answer

Emergency department visit

Question 8

For accurate CPT coding of evaluation and management services, which element is crucial?

Accepted Answer

Thoroughly documenting the patient's history, physical exam, and decision-making

Answer

Solely relying on the patient's main concern

Answer

Always selecting the highest level of service code

Question 9

Which factor is NOT considered when determining the level of an E/M service?

Accepted Answer

Age of the patient

Answer

Number of diagnoses

Answer

Time spent interacting with the patient

Answer

Complexity of medical decision-making

Question 10

What is the primary purpose of the CPT codebook?

Accepted Answer

Provide guidance on coding medical services

Answer

Establish reimbursement rates for medical services

Answer

Track the utilization of medical services

Answer

Ensure the quality of medical services

Question 11

Which of the following is NOT a factor considered in determining the level of medical decision-making for E/M services?

Accepted Answer

Patient's age and gender

Answer

Number of diagnoses or management options

Answer

Amount of data reviewed

Answer

Complexity of medical problems

Question 12

What is the primary factor considered when determining the appropriate level of coding for Evaluation and Management (E/M) services?

Accepted Answer

Medical complexity of the patient's condition

Answer

Time spent with the patient

Answer

Patient's age

Answer

Reason for the visit

Question 13

In the context of E/M services, which component of the medical history is typically excluded from the initial level?

Accepted Answer

Social history

Answer

Current medications

Answer

Review of systems

Answer

Past medical history

Question 14

For a patient's medical decision-making to be considered 'low complexity', which scenario applies:

Accepted Answer

The diagnosis or treatment is straightforward and requires minimal effort

Answer

Multiple diagnoses or treatment options are present

Answer

The physician consults with another provider

Answer

The patient is critically ill

Question 15

CPT codes used for E/M services are categorized based on:

Accepted Answer

Level of complexity

Answer

Age of the patient

Answer

Location of the service

Answer

Provider's specialty

Question 16

Which of the following factors is a key criterion in determining the level of service for an E/M service?

Accepted Answer

Medical decision-making

Answer

Patient's age

Answer

Time spent with the patient

Answer

Procedure performed

Question 17

What is the primary purpose of using modifiers with E/M codes?

Accepted Answer

To indicate additional services or circumstances that affect the coding.

Answer

To replace the main E/M code

Answer

To reduce the reimbursement for the service.

Question 18

Provide a concise definition of a "significant, separately identifiable E/M service" in the context of E/M coding.

Accepted Answer

A service that is distinct from the primary E/M service and requires a separate history, exam, and medical decision-making.

Answer

A service that is provided on the same day as the primary E/M service.

Question 19

Which of the following documentation elements is NOT a required component to establish medical necessity for an E/M service?

Accepted Answer

Patient's signature

Answer

Physical exam findings

Answer

Medical history

Answer

Medical decision-making

Question 20

Which of the following is a crucial component of medical decision-making in CPT coding?

Accepted Answer

Number and complexity of medical problems addressed

Answer

Length of the encounter

Answer

Age of the patient

Answer

Patient's insurance status

Question 21

A patient with a history of diabetes presents for a follow-up visit. They have a new onset of numbness and tingling in their feet. Which CPT code should be assigned for this encounter?

Accepted Answer

99214

Answer

99212

Answer

99203

Answer

99215

Question 22

Which factor is NOT considered when determining the level of medical decision-making (MDM)?

Accepted Answer

Patient's age

Answer

Amount of data reviewed

Answer

Complexity of the problem

Answer

Number of diagnoses or management options

Question 23

A child comes in for a well-child checkup. The doctor takes a detailed medical history, does a complete physical exam, orders routine lab tests, and gives immunizations. Which CPT code is appropriate for this visit?

Accepted Answer

99391 - Office or other outpatient visit, new patient, preventive medicine

Answer

99203 - Office or other outpatient visit, level 3

Answer

99202 - Office or other outpatient visit, level 2

Question 24

Which of the following is NOT a key part of a comprehensive history?

Accepted Answer

Review of systems (ROS) is not performed

Answer

Detailed review of patient's past medical history

Answer

Social history, including habits and lifestyle

Answer

Family history of relevant conditions

Question 25

Which statement about CPT codes for E/M services is most accurate?

Accepted Answer

They are based on how complex the patient's medical problem is and the level of service provided.

Answer

They are always the same for similar patient conditions.

Answer

They are mainly determined by the amount of time spent with the patient.