6/9/26, 3:33 Ch 19 - Review Assessment
PM
The provider saw an established patient in his office and 99222,
99214-25 decided to admit an 18-month-old infant to the hospital
from his office to rule out sepsis. The infant is crying Rationale: According to CPT® guidelines: "When the patient is
admitted to the inconsolably. He has a large amount of gas in his bowel, hospital as an inpatient or to observation status in
the course of an encounter in no hematochezia associated with it. The provider another site of service (eg, hospital
emergency department, office, nursing facility),
documented two distinct notes and saw the patient in the the services in the initial site may be separately reported.
Modifier 25 may be added office and in the hospital. A medically appropriate history to the other evaluation and
management service to indicate a significant, separately and exam were documented in both settings.In the identifiable service
by the same physician or other qualified health care professional hospital, the provider ordered a CBC, EKG and chest x-ray
was performed on the same date." The provider admitted the infant to
the hospital and started the patient on antibiotics. If cultures are from his office and continued the care on the same date of
service. The provider negative and the patient remains afebrile for 48 hours, the documented a new problem with uncertain
prognosis and admission to the hospital infant will be discharged home. According to the CPT® to support a moderate
complexity MDM in the office on an established patient,
E/M guidelines, what CPT® code is reported for this visit? 99214 with modifier 25. In the hospital, the provider ordered three
unique test and
prescription drug management for a moderate complexity. The
appropriate code is 99222.
A patient is seen for hypertension. Her provider has her on Chronic illness with exacerbation, progression, or side
effects of treatment. prescriptions, but her blood pressure is not yet at goal. The
patient does not exhibit any symptoms. When referring to Rationale: According to the CPT® E/M guidelines, a stable,
chronic illness is a the number and complexity of problems addressed, what chronic illness that is at goal. The
patient's hypertension is not yet at goal. Even type of problem is this considered? though there are no symptoms exhibited,
this is considered a chronic illness with
exacerbation, progression, or side effects of treatment.
A 32-year-old patient sees Dr. Smith for a consult at the
99243 request of his PCP, Dr. Long, for an ongoing problem
with
allergies. The patient has failed Claritin and Alavert and Rationale: The three Rs of consultation are documented (request,
render, reply). feels his symptoms continue to worsen. Dr. Smith performs The consultation code range is 99242-99245 and
applies to new or established a medically appropriate history and exam and discusses patients. The ongoing problem
with allergies is a chronic problem that is not
options with the patient on allergy management. The controlled (moderate problem). The provider orders allergy testing (1
test - minimal patient agrees he would like to be tested to possibly gain data). There is low risk with allergy testing. Medical
decision making is low. 99243 is better control of his allergies. Dr. Smith sends a report to reported.
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?
An established patient presents to the clinic today for a
99214 follow-up of his pneumonia. He was hospitalized for 6
days
on IV antibiotics. He was placed back on Singulair and has Rationale: The patient was seen in the clinic which is an
outpatient service. Medical been doing well with his breathing since then. Exam was decision making is the determining
factor for selecting E/M level. Number and performed. Provider reviewed the complete blood count Complexity of Problems
Addressed is Moderate for an acute illness with systemic lab from the hospital and personally viewed and symptoms
(Moderate). The pneumonia is still being treated and is considered as interpreted a recent chest X-ray that shows the right lung
acute. Data Reviewed and Analyzed includes a review of lab from the
hospital and with infiltrates. The patient was told to continue antibiotics independent visualization of the chest X-ray
(Moderate). Prescription drug
for another two weeks to 20 days, and the prescription management (Moderate risk). MDM is moderate reporting 99214.
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?
Subjective: 6-year-old girl twisted her arm on the
99283 playground. She is seen in the ED complaining of pain
in
her wrist. Rationale: The provider performed a medically appropriate history and
exam with a low MDM (acute uncomplicated injury, order of unique test
[X-ray], and low level of risk). A low complexity MDM supports a 99283.
Dr. X asks Dr. Y to look at a 55-year-old male who is in a
99253 nursing facility for decubitus ulceration. Dr. Y is
unable to
obtain history due to current mental status. He obtains a Rationale: Dr. X asks Dr. Y to perform a consultation on a patient
residing in a history from Dr. X because the patient is unable to provide nursing facility. According to CPT® guidelines:
"The initial inpatient consultation a history. An exam along with low MDM is performed. Dr Y. codes (99252-99255),
/ch-19-review-s/ 1/
6
, 6/9/26, 3:33 Ch 19 - Review Assessment
PM
are to be used only once by the reporting provider for an
recommends to Dr. X that the patient needs to go to the individual hospital or nursing facility patient for a particular admission.
These codes surgical suite for debridement of the ulcerations. Since the are to be reported for consultations provided to
hospital inpatients, residents of patient is unstable at the moment due to elevated blood nursing facilities, or patients in a
partial hospital setting." A consultation is a type of pressure and a UTI, they decide to delay surgery and to service provided
by a provider whose opinion or advice regarding evaluation and /or keep monitoring the patient until he stabilizes. Written
management of a specific problem is requested by another provider.
The consulting report is documented. What CPT® code is reported? provider performs the consultation, documents his or
her opinion in the patient's
medical record, and communicates findings/recommendations by
written report to the requesting provider or other appropriate source.
Consultations require the documentation of three of three key
components. The provider performed a low MDM. The correct code is
99253.
ICU - CC: Multi-system organ failure INTERVAL HISTORY:
99291 Patient remains intubated and sedated. Overnight
events
reviewed. Tolerating tube feeds. Systolic pressures have Rationale: This patient meets the definition of a critically ill patient as
defined by the been running in the low 90s on LEVOPHED. Cultures E/M Guidelines for Critical Care services. A critical
illness is one acutely impairing remain negative. Kidney function has worsened, but one or more vital organ system with
a high probability of imminent or life threatening patient remains non-oliguric.PHYSICAL EXAM: BP 96/60, deterioration in the
patient's condition. The physician documents 35 minutes of Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart
critical care time. Critical care for 35 minutes is reported with 99291.
RRR with no MRGs. Abdomen is soft with positive
bowel sounds. Extremities show moderate
edema.LABS: BUN 89, creatinine 2.6, HGB 10.2,
WBC 22,000. ABG:
7.34/100/42 on 50% FiO2. CXR shows RLL
infiltrate.IMPRESSION Hypoxic respiratory
failureCommunity acquired pneumoniaSeptic
shockNon-oliguric acute renal failurePLAN:
Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25
grams IV Q 6HFollow cultures. Continue tube
feeds. Titrate LEVOPHED to maintain SBP
> 90Usual labs ordered for tomorrow.Critical care time: 35
minutesWhat CPT® code(s) is/are reported
A 60-year-old woman is seeking help to quit smoking. She
99203 makes an appointment to see Dr. Lung for an initial
visit.
The patient has a constant cough due to smoking and Rationale: Patient is coming to the provider's office for help to quit
smoking. The some shortness of breath. No night sweats, weight loss, patient is new. The provider documents 32 minutes
total time. 99203 has a range of night fever, CP, headache or dizziness. She has tried time 30-44 minutes.
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.
Total time spent with the patient was 32 minutes.
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.
A 5-year-old is brought to the Emergency Department by 92950, 99291-25, 36556,
31500 ambulance, He had been found floating in a pool for an
unknown amount of time. EMS started CPR which was Rationale: ED provider documents an amount of time spent with this
critical patient. continued by the ED provider along with endotracheal According to CPT® guidelines: "The critical care
codes 99291 and 99292 are used intubation and placement of a CVC. The ER provider spent to report the total duration
of time spent by a provider providing critical care services 1 hour with the critically ill patient. The ED provider makes to
a critically ill or critically injured patient. Time spent with individual patient is
a notation the 1 hour does not include the time for the recorded in the patient's record." According to CPT® guidelines:
"Services such as other separate billable services. What CPT® codes are endotracheal intubation (31500) and
cardiopulmonary resuscitation (92950) are not reported? included in the critical care codes. Therefore, they can be coded
separately in
addition to critical care services if the critical care is a significant,
separately identifiable service, and is reported with modifier -25. The
time spent performing these other services, for example endotracheal
intubation, is excluded from the determination of the time spent
providing critical care." In the CPT® Index look for Cardiopulmonary
Resuscitation (CPR) referring you to code 92950. Review code to verify
accuracy. In the CPT® Index look for Catheterization/Central referring
you to codes 36555-36566. 36556 is the correct code because the
patient is 5 years of age and there is no indication the CVC was
/ch-19-review-s/ 2/
6
PM
The provider saw an established patient in his office and 99222,
99214-25 decided to admit an 18-month-old infant to the hospital
from his office to rule out sepsis. The infant is crying Rationale: According to CPT® guidelines: "When the patient is
admitted to the inconsolably. He has a large amount of gas in his bowel, hospital as an inpatient or to observation status in
the course of an encounter in no hematochezia associated with it. The provider another site of service (eg, hospital
emergency department, office, nursing facility),
documented two distinct notes and saw the patient in the the services in the initial site may be separately reported.
Modifier 25 may be added office and in the hospital. A medically appropriate history to the other evaluation and
management service to indicate a significant, separately and exam were documented in both settings.In the identifiable service
by the same physician or other qualified health care professional hospital, the provider ordered a CBC, EKG and chest x-ray
was performed on the same date." The provider admitted the infant to
the hospital and started the patient on antibiotics. If cultures are from his office and continued the care on the same date of
service. The provider negative and the patient remains afebrile for 48 hours, the documented a new problem with uncertain
prognosis and admission to the hospital infant will be discharged home. According to the CPT® to support a moderate
complexity MDM in the office on an established patient,
E/M guidelines, what CPT® code is reported for this visit? 99214 with modifier 25. In the hospital, the provider ordered three
unique test and
prescription drug management for a moderate complexity. The
appropriate code is 99222.
A patient is seen for hypertension. Her provider has her on Chronic illness with exacerbation, progression, or side
effects of treatment. prescriptions, but her blood pressure is not yet at goal. The
patient does not exhibit any symptoms. When referring to Rationale: According to the CPT® E/M guidelines, a stable,
chronic illness is a the number and complexity of problems addressed, what chronic illness that is at goal. The
patient's hypertension is not yet at goal. Even type of problem is this considered? though there are no symptoms exhibited,
this is considered a chronic illness with
exacerbation, progression, or side effects of treatment.
A 32-year-old patient sees Dr. Smith for a consult at the
99243 request of his PCP, Dr. Long, for an ongoing problem
with
allergies. The patient has failed Claritin and Alavert and Rationale: The three Rs of consultation are documented (request,
render, reply). feels his symptoms continue to worsen. Dr. Smith performs The consultation code range is 99242-99245 and
applies to new or established a medically appropriate history and exam and discusses patients. The ongoing problem
with allergies is a chronic problem that is not
options with the patient on allergy management. The controlled (moderate problem). The provider orders allergy testing (1
test - minimal patient agrees he would like to be tested to possibly gain data). There is low risk with allergy testing. Medical
decision making is low. 99243 is better control of his allergies. Dr. Smith sends a report to reported.
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?
An established patient presents to the clinic today for a
99214 follow-up of his pneumonia. He was hospitalized for 6
days
on IV antibiotics. He was placed back on Singulair and has Rationale: The patient was seen in the clinic which is an
outpatient service. Medical been doing well with his breathing since then. Exam was decision making is the determining
factor for selecting E/M level. Number and performed. Provider reviewed the complete blood count Complexity of Problems
Addressed is Moderate for an acute illness with systemic lab from the hospital and personally viewed and symptoms
(Moderate). The pneumonia is still being treated and is considered as interpreted a recent chest X-ray that shows the right lung
acute. Data Reviewed and Analyzed includes a review of lab from the
hospital and with infiltrates. The patient was told to continue antibiotics independent visualization of the chest X-ray
(Moderate). Prescription drug
for another two weeks to 20 days, and the prescription management (Moderate risk). MDM is moderate reporting 99214.
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?
Subjective: 6-year-old girl twisted her arm on the
99283 playground. She is seen in the ED complaining of pain
in
her wrist. Rationale: The provider performed a medically appropriate history and
exam with a low MDM (acute uncomplicated injury, order of unique test
[X-ray], and low level of risk). A low complexity MDM supports a 99283.
Dr. X asks Dr. Y to look at a 55-year-old male who is in a
99253 nursing facility for decubitus ulceration. Dr. Y is
unable to
obtain history due to current mental status. He obtains a Rationale: Dr. X asks Dr. Y to perform a consultation on a patient
residing in a history from Dr. X because the patient is unable to provide nursing facility. According to CPT® guidelines:
"The initial inpatient consultation a history. An exam along with low MDM is performed. Dr Y. codes (99252-99255),
/ch-19-review-s/ 1/
6
, 6/9/26, 3:33 Ch 19 - Review Assessment
PM
are to be used only once by the reporting provider for an
recommends to Dr. X that the patient needs to go to the individual hospital or nursing facility patient for a particular admission.
These codes surgical suite for debridement of the ulcerations. Since the are to be reported for consultations provided to
hospital inpatients, residents of patient is unstable at the moment due to elevated blood nursing facilities, or patients in a
partial hospital setting." A consultation is a type of pressure and a UTI, they decide to delay surgery and to service provided
by a provider whose opinion or advice regarding evaluation and /or keep monitoring the patient until he stabilizes. Written
management of a specific problem is requested by another provider.
The consulting report is documented. What CPT® code is reported? provider performs the consultation, documents his or
her opinion in the patient's
medical record, and communicates findings/recommendations by
written report to the requesting provider or other appropriate source.
Consultations require the documentation of three of three key
components. The provider performed a low MDM. The correct code is
99253.
ICU - CC: Multi-system organ failure INTERVAL HISTORY:
99291 Patient remains intubated and sedated. Overnight
events
reviewed. Tolerating tube feeds. Systolic pressures have Rationale: This patient meets the definition of a critically ill patient as
defined by the been running in the low 90s on LEVOPHED. Cultures E/M Guidelines for Critical Care services. A critical
illness is one acutely impairing remain negative. Kidney function has worsened, but one or more vital organ system with
a high probability of imminent or life threatening patient remains non-oliguric.PHYSICAL EXAM: BP 96/60, deterioration in the
patient's condition. The physician documents 35 minutes of Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart
critical care time. Critical care for 35 minutes is reported with 99291.
RRR with no MRGs. Abdomen is soft with positive
bowel sounds. Extremities show moderate
edema.LABS: BUN 89, creatinine 2.6, HGB 10.2,
WBC 22,000. ABG:
7.34/100/42 on 50% FiO2. CXR shows RLL
infiltrate.IMPRESSION Hypoxic respiratory
failureCommunity acquired pneumoniaSeptic
shockNon-oliguric acute renal failurePLAN:
Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25
grams IV Q 6HFollow cultures. Continue tube
feeds. Titrate LEVOPHED to maintain SBP
> 90Usual labs ordered for tomorrow.Critical care time: 35
minutesWhat CPT® code(s) is/are reported
A 60-year-old woman is seeking help to quit smoking. She
99203 makes an appointment to see Dr. Lung for an initial
visit.
The patient has a constant cough due to smoking and Rationale: Patient is coming to the provider's office for help to quit
smoking. The some shortness of breath. No night sweats, weight loss, patient is new. The provider documents 32 minutes
total time. 99203 has a range of night fever, CP, headache or dizziness. She has tried time 30-44 minutes.
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.
Total time spent with the patient was 32 minutes.
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.
A 5-year-old is brought to the Emergency Department by 92950, 99291-25, 36556,
31500 ambulance, He had been found floating in a pool for an
unknown amount of time. EMS started CPR which was Rationale: ED provider documents an amount of time spent with this
critical patient. continued by the ED provider along with endotracheal According to CPT® guidelines: "The critical care
codes 99291 and 99292 are used intubation and placement of a CVC. The ER provider spent to report the total duration
of time spent by a provider providing critical care services 1 hour with the critically ill patient. The ED provider makes to
a critically ill or critically injured patient. Time spent with individual patient is
a notation the 1 hour does not include the time for the recorded in the patient's record." According to CPT® guidelines:
"Services such as other separate billable services. What CPT® codes are endotracheal intubation (31500) and
cardiopulmonary resuscitation (92950) are not reported? included in the critical care codes. Therefore, they can be coded
separately in
addition to critical care services if the critical care is a significant,
separately identifiable service, and is reported with modifier -25. The
time spent performing these other services, for example endotracheal
intubation, is excluded from the determination of the time spent
providing critical care." In the CPT® Index look for Cardiopulmonary
Resuscitation (CPR) referring you to code 92950. Review code to verify
accuracy. In the CPT® Index look for Catheterization/Central referring
you to codes 36555-36566. 36556 is the correct code because the
patient is 5 years of age and there is no indication the CVC was
/ch-19-review-s/ 2/
6
