9. Coding Practice Questions and
Answers Complete Solutions
A four year old female established patient received Evaluation and Management Services, which
included a problem focused history, an expanded problem focused exam, and medical decision
making of a low level. The patient is diagnosed with influenza. Ans- 99213
A 16 year old outpatient who is a new patient to the office complans of severe facial acne. The
history and physical examination are expanded problem focused. The physician must consider
related organ systems in addition to the integumentary system in order to treat the condition.
With minimal number of diagnoses to consider and the minimal amount of data to review, the
physicians decision making is straightforward with regard to the treatment of this patient. Ans-
99202
A patient was in an automobile accident and is complaining of a minor headache and no other
apparent injuries. HIstory gathered from the bystanders states that the patient was not wearing a
seat belt and hit his head on the windshield. A 15 minute loss of consciousness was noted. The
patient was then admitted for 24 hour observation to rule out head injury. A comprehensive
history and exam are performed by the physician. The MDM is of moderate complexity. Ans-
99219
, A 55 year old female came in with the complaint of severe abdominal pain. The patient was
admitted on 05-07 for observation due to the severity and location of her pain. The admitting
physician performed a comprehensive history and a detailed examination and documented
medical decision making of a moderate complexity given the amount of possible diagnoses,
including appendicitis, gastric ulcer, cholelithiasis and pyelonephritis. Various diagnostic tests
were ordered and done, including barium enema, upper gastrointestinal endoscopy, and KUB
(kidneys, ureters, bladder) x-ray. No disease or disorder was found, and the patient was
discharged from observation on 05-08. The patient reported a decrease in her pain after 30 hours
of IV analgesics and antispasmodics. The physician documented that the patient should follow
up with her primary care physician in 2 days or return to the hospital if the pain worsens. The
physician also documented a final detailed examination of the patient and dictated a discharge
summary report. Ans- 99218, 99217
A 50 year old female patient was admitted to the hospital on 10-10 with a diagnosis of
pneumonia due to Staphylococcus aureus, at which time she received level 2 E/M services from
her attending physician. On 10/11 and 10/12 the patient received level 2 E/M services. On 10/13,
the patient was dischared from the hospital in improved condition to follow up with the
physician at home; the physician spent 30 minutes performing discharge day management
functions. Ans- 99222, 99232, 99238, 99238
An established patient is seen in the hospital on day two of his hospital stay. The patient had
been admitted through the emergency department with status asthmaticus and had been
Answers Complete Solutions
A four year old female established patient received Evaluation and Management Services, which
included a problem focused history, an expanded problem focused exam, and medical decision
making of a low level. The patient is diagnosed with influenza. Ans- 99213
A 16 year old outpatient who is a new patient to the office complans of severe facial acne. The
history and physical examination are expanded problem focused. The physician must consider
related organ systems in addition to the integumentary system in order to treat the condition.
With minimal number of diagnoses to consider and the minimal amount of data to review, the
physicians decision making is straightforward with regard to the treatment of this patient. Ans-
99202
A patient was in an automobile accident and is complaining of a minor headache and no other
apparent injuries. HIstory gathered from the bystanders states that the patient was not wearing a
seat belt and hit his head on the windshield. A 15 minute loss of consciousness was noted. The
patient was then admitted for 24 hour observation to rule out head injury. A comprehensive
history and exam are performed by the physician. The MDM is of moderate complexity. Ans-
99219
, A 55 year old female came in with the complaint of severe abdominal pain. The patient was
admitted on 05-07 for observation due to the severity and location of her pain. The admitting
physician performed a comprehensive history and a detailed examination and documented
medical decision making of a moderate complexity given the amount of possible diagnoses,
including appendicitis, gastric ulcer, cholelithiasis and pyelonephritis. Various diagnostic tests
were ordered and done, including barium enema, upper gastrointestinal endoscopy, and KUB
(kidneys, ureters, bladder) x-ray. No disease or disorder was found, and the patient was
discharged from observation on 05-08. The patient reported a decrease in her pain after 30 hours
of IV analgesics and antispasmodics. The physician documented that the patient should follow
up with her primary care physician in 2 days or return to the hospital if the pain worsens. The
physician also documented a final detailed examination of the patient and dictated a discharge
summary report. Ans- 99218, 99217
A 50 year old female patient was admitted to the hospital on 10-10 with a diagnosis of
pneumonia due to Staphylococcus aureus, at which time she received level 2 E/M services from
her attending physician. On 10/11 and 10/12 the patient received level 2 E/M services. On 10/13,
the patient was dischared from the hospital in improved condition to follow up with the
physician at home; the physician spent 30 minutes performing discharge day management
functions. Ans- 99222, 99232, 99238, 99238
An established patient is seen in the hospital on day two of his hospital stay. The patient had
been admitted through the emergency department with status asthmaticus and had been
