EVALUATION AND MANAGEMENT (E&M)

61. 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.

62. James, a 35-year-old new patient, received 45minutesof counseling and risk factor reduction

intervention services from Dr.Kelly. Dr.Kelly talked to James about how toavoid sports injuries.

Currently, James does not have any symptoms or injuries and wants to maintain this status. This was

the only service rendered. How do you code?

a. 99213

b. 99203

c. 99385

d. 99403

63. 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
singleview 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
64. Brandon was seen in Dr. Shaw’s office after falling off his bunkbed. 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 decisionmaking
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 for today’s visit?

a. 99204

b. 99394,99214

c. 99214

d. 99203

65. Adam, a48-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
xray. 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

66. Why are the following codes not reported with continuing intensive care services (99478–

99480):36510,36000,43752, 51100,94660,or94375?

a. These codes are deleted from the CPT 2019 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.

67. 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 90days of therapy including 8 INR measurements?

a. 99363

b. 99495

c. 99214

d. This service is bundled with evaluation and management services

68. 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

highcomplexity 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 straight forward 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 today five?

a. 99213,99232,99231, 99239x2

b. 99221,99222,99223, 99238

c. 99231,99232,99355, 99217

d. 99223,99232,99232, 99231,99239

69. Which code range would describe services for a critically ill patient, who is 23 days old as an

outpatient?

a. 99291–99292

b. 99471–99446

c. 99466–99467

d. None of the above

70. Mr. Johnson, a38-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

71. 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 24hours 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.

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

a. 99392

b. 99213-25, 99385

c.99203

d. 99382

Question 62

EVALUATION AND MANAGEMENT (E&M)

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

Question 63

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. Prescription was given to help with the anxiety. What CPT® code should be reported?

A. 99203 B. 99204

C. 99244 D. 99214

Question 64

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 moderate MDM. 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 30 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. 99214, 99354

Question 65
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

Question 66

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

Question 67

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

Question 68

In order to use the critical care codes, which of the following statements is TRUE?

A. Critical care services can be provided in an internist’s office

B. Critical care services provided for more than 15 minutes but less than 30 minutes should be

billed with 99291 and modifier 52.

C. Time spent reviewing laboratory test results or discussing the critically ill patient’s care with

other medical staff in the unit or at the nursing station on the floor cannot be included in the

determination of critical care time.

D. Critical care services can only be billed if the patient is in a licensed emergency room or

intensive care type unit (i.e., cardiac, surgical, respiratory).

Question 69

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. Select the appropriate

CPT® code for this visit?

A. 99203 B. 99204

C. 99214 D. 99244

Question 70

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 oxymetry,

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, 99151,99153 B. 99284-25, 99155,99157

C. 99283-25, 99151 D. 99283

Question 71

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 Xray 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

Question 72

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
6.

EVALUATION AND MANAGEMENT (E&M)

Question 61

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® and ICD-10CM codes should be used for this

service?

A. 99201, Z97.5 B. 99211, Z44.8 C. 99202, T83.6XXA D. 99212, Z46.89

Question 62

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

Question 63

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

Question 64

50-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. 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

Question 65

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

Question 66

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

Question 67

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. 99201

B. 99202

C. 99212

D. 99213

Question 68

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 high complexity. Which E/M service supports this documentation?

A. 99205

B. 99204

C. 99203

D. 99202

Question 69

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

Question 70

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. What CPT® and ICD-10-CM codes should be reported?

A. 99212, J02.9, H66.90

B. 99213, J02.0, H65.90

C. 99212, J02.0, H65.199

D. 99213, J02.0, H65.199