A provider admits Mrs. Smith to the hospital. She is there for five days. The provider sees her each day she's in the hospital. What subcategory of E/M codes would be used for days two, three and four... ? - ANSWER Subsequent Hospital Care If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)? - ANSWER Quality What modifier is used to report an evaluation and management service mandated by a court order? - ANSWER 32 According to CPT® guidelines what is the first step in selecting an evaluation and management code? - ANSWER Determine the category and subcategory Fred is fishing at the local area lake while on vacation. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. He's evaluated by the ED provider. This is the first time he has been to this hospital. What subsection is used to report the ED visit? - ANSWER Emergency Department Services A 77 year-old Medicare beneficiary has a digital rectal examination for prostate cancer screening and the provider orders a PSA. How would this be reported? - ANSWER G0102 A 75 year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. A comprehensive history and examination is performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported? - ANSWER 99397 What ICD-10-CM code is reported for vertigo? - ANSWER R42 A provider makes a home care visit to a 63 year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home bound for the last year. The last visit from this provider was four months ago to manage his DM. The physician performs an expanded problem focused examination and low MDM. The provider speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported? - ANSWER 99348 A 32 year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported? - ANSWER 99242 Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit? - ANSWER 99213, 99354 What ICD-10-CM code is reported for angina pectoris with a documented spasm? - ANSWER I20.1 What ICD-10-CM code is reported for nausea and vomiting? - ANSWER R11.2 A 10 year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs an expanded problem history and exam and treats the patient for a URI. What CPT® code(s) is/are reported for this visit? - ANSWER 99393, 99213-25 A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter? - ANSWER 99475 New Patient History & Physical CHIEF COMPLAINT: Right inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44 year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. MEDICATIONS: Advair. ALLERGIES: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69. GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. LYMPH NODES: None. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear to auscultation. HEART: Regular rhythm with no murmur. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal. IMPRESSION: Right indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number, and he will call and arrange the operation. What CPT® and ICD-10-CM codes are reported? - ANSWER 99203, K40.90 A 33 year-old male was admitted to the hospital on 12/17/XX from the ER following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending provider performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The provider spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit? - ANSWER 99238 A 45 year-old established, female patient is seen today at her provider's office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems are performed. This is a new problem. An EKG is ordered and labs are drawn, and the provider documents a moderate complexity MDM. What CPT® code is reported for this visit? - ANSWER 99214 Subjective: 6 year-old girl twisted her arm on the playground. She is seen in the ED complaining of pain in her wrist. Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal Assessment: Wrist sprain Plan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement. What is the E/M code for this visit? - ANSWER 99281 Dr. X asks Dr. Y to look at a 65 year-old male who is in a nursing facility for decubitus ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a detailed history from Dr. X since the patient is unable to provide a history. A detailed exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to the surgical suite for debridement of the ulcerations. Since the patient is unstable at the moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep monitoring the patient until he stabilizes. Written report is documented. What CPT® code is reported? - ANSWER 99253 A 60 year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30-minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit. - ANSWER 99203 Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit? - ANSWER 99239, 99304 A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter? - ANSWER 99214, K37, R12 An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit? - ANSWER 20610-50 Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk but her mother has returned to work and is using a breast pump but hasn't seemed to produce enough milk. PHYSICAL EXAM: Weight 12 lbs. 11 oz., Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week. ASSESSMENT Four month-old well check Cold Mild thrush Diaper rash PLAN: Okay to advance to baby foods Okay to supplement with Similac Nystatin suspension for the thrush and creams for the diaper rash if it recurs Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polio What E/M code(s) is/are reported? - ANS [Show More]
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