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1. An infant is born six weeks premature in rural Arizona and the pediatrician in attendance
intubates the child and administers surfactant in the ET tube while waiting in the ER for
the air ambulance. During the 45-minute wait, he continues to bag the critically ill
patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and
temperature. The infant is in a warming unit and an umbilical vein line was placed for
fluids and in case of emergent need for medications. How is this coded? - Correct
Answer: 99291-25, 31500, 36510, 94610
2. The physician was called to the hospital floor for the medical management of a 56 year-
old patient admitted one day ago with aspiration pneumonia and COPD. No chest pain at
present, but still SOB and some swelling in his lower extremities. Patient was tachypneic
yesterday; lungs reveal course crackles in both bases, right worse than left. The physician
writes instructions to continue with intravenous antibiotic treatment and respiratory
support with ventilator management. He reviewed chest X-ray and labs. Patient is
improving and a pulmonary consultation has been requested. What CPT® code is
reported? - Correct Answer: 99231
3. An established 47 year-old patient presents to the provider's office after falling last night
in her apartment when she slipped in water on the kitchen floor. She is complaining of
low back pain and no tingling or numbness. Provider documents that she has full range
motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising
is negative. She requested no medication. It is recommended to use heat, such as a hot
, water bottle. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD-10-
CM codes are reported for this service? - Correct Answer: 99213, S39.012A,
W01.0XXA, Y92.030
4. A 5 year-old is brought to the Emergency Department by ambulance, He had been found
floating in a pool for an unknown amount of time. EMS started CPR which was continued
by the ED provider along with endotracheal intubation and placement of a CVC. The ER
provider spent 1 hour with the critically ill patient. The ED provider makes a notation the
1 hour does not include the time for the other separate billable services. What CPT®
codes are reported? - Correct Answer: 92950, 99291-25, 36556, 31500
5. An established patient presents to the clinic today for a follow-up of his pneumonia. He
was hospitalized for 6 days on IV antibiotics. He was placed back on Singulair and has
been doing well with his breathing since then. An expanded problem focused exam was
performed. Records were obtained from the hospital and the provider reviewed the labs
and X-rays. The patient was told to continue antibiotics for another two weeks to 20
days, and the prescription Keteck was replaced with Zithromax. Patient is to return to
the clinic in two weeks for recheck of his breathing and follow up X-ray. What CPT® code
is reported? - Correct Answer: 99213
6. 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? - Correct
Answer: 99214, K37, R12
7. 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? - Correct Answer: 20610-50
, 8. Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest
pain which radiates down his left arm. The paramedics are called to the casino he owns
in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to
direct the activities of the paramedics. He spends 30 minutes in two-way communication
directing the care of Mr. Trumph. When EMS reached the hospital Emergency
Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular
tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR.
Defibrillation is performed with 250 joules to a NSR. What are the appropriate
procedure codes for this encounter? - Correct Answer: 99288, 99291, 92950
9. Dr. Jones documents Mrs. Smith's condition has improved during his third visit to her
hospital room. Upon entering the room, he finds her sitting up in bed, watching
television and eating breakfast. Dr. Jones performs a problem focused exam and a low
medical decision making. What CPT® code should be reported? - Correct Answer:
99232
Examples of settings include:
Office or other outpatient setting
Inpatient Hospital
Emergency department (ED)
Nursing facility (NF)
Outpatient Hospital - Correct Answer: E/M services are further categorized based on the
setting in which the service is provided. What are they??
10. History
Exam
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
, Time - Correct Answer: Components used in
selecting a level of E/M service.
11. HPI (History of Present Illness) 7.
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs/Symptoms. - Correct Answer: HPI (History of Present Illness) Elements?
12. The physician should have an understanding as to the location of the problem.
For example, if a patient complains of pain, a physician should ask if the pain is diffuse or
localized, unilateral or bilateral? Does it radiate or is it referred to another location? The
physician may also ask the patient to point to the specific area. - Correct Answer: Location:
13. The physician should encourage the patient to describe the quality of the symptoms, since
some diseases or conditions produce specific patterns of complaints. For example, pain may be
described as sharp, dull, throbbing, stabbing, acute or chronic, stable, improving or worsening. -
Correct Answer: Quality:
14. The physician should get some idea about the severity of the discomfort or sensation or
pain. The patient may describe the severity of the pain by employing a crude self-assessment
scale to measure subjective levels (e.g. 1-10) with one being no pain and 10 the worst pain
experience. The pain may also be estimated through nonverbal signals of discomfort, such as
the patient lying perfectly still or continuously pacing the floor. - Correct Answer: Severity: