Chpt 3

Question 1

Evaluation and Management

Answer 1

1st section of CPT
Billable services
1st evaluation by healthcare provider
Then implement management plan and record in the medical record

Question 2

Original guidelines for E/M

Answer 2

AMA & CMS
1995 & 1997
Labor intensive to document all the components needed for code justification
Be aware for audits of retrospective period
Internet links for both at CMS.gov

Question 3

Revised guidelines

Answer 3

January 1, 2021, AMA -streamlined 99202-99215
January 1, 2023 for other CPT codes

Question 4

E/M code questions

Answer 4

Is the patient new or established?
Where was the service provided?
What was the level of the service rendered?

Question 5

New patient points

Answer 5

Same specialty or subspecialty
Same group practice
Three years

Question 6

Place of Service code

Answer 6

Different than E/M code
Box 24B of CMS-1500
Codes maintained by CMS

Question 7

Medical decision making

Answer 7

The number and complexity of problems addressed at the encounter
The amount and/or complexity of data reviewed and analyzed
The risk of complications and/or morbidity or mortality of patient management

Question 8

Risks of complications level

Answer 8

Minimal, low, moderate, high
Based on the risks associated with presenting problems, the diagnostic procedures and possible management problems

Question 9

Determine the amount and complexity of the data reviewed

Answer 9

More tests and procedures reviewed by the provider, the higher the level of this element
The review of of a report can be documented with a provider note or the provider can initial and date the report
If the provider personally reviews the specimen or image they ordered, the complexity of the reviewed data increases
When documenting the complexity of data reviewed, providers should clearly document the information in order to justify the types of data reviewed
The risk of complications and/or mortality or morbidity of patient management

Question 10

Select type of risk

Answer 10

Comorbidities and underlying diseases increase the complexity of risk
Surgical and invasive procedures performed during the encounter increase risk
Problems that pose a threat to life or bodily function increase risk
The more complex the diagnostic tests ordered, the greater the risk
The more complex the management options ordered are, the greater the risk

Question 11

4 types of medical decision making regardless of location

Answer 11

Straightforward, low, moderate , high

Question 12

99211

Answer 12

Reported for an office or outpatient visit for an established patient that does not require the presence of a physician or other healthcare provider

Question 13

MDM

Answer 13

Justification of MDM is provider’s documentation

Question 14

MDM Tables

Answer 14

List the specific elements that are needed for each type of MDM.
2 of 3 elements must be met or exceeded to qualify for a specific level of MDM

Question 15

MDM decided on time

Answer 15

Requires a face-to-face encounter between the provider and the physician

Question 16

ROS

Answer 16

Review of systems
Obtained by querying the patient

Question 17

PFSH

Answer 17

Past, family and/or social history
Past: any past medical information that may affect the decision-making process

Question 18

Office POS

Answer 18

11

Question 19

School POS

Answer 19

3

Question 20

Home POS

Answer 20

12

Question 21

Assisted living facility

Answer 21

13

Question 22

Urgent care facility POS

Answer 22

20

Question 23

Inpatient hospital POS

Answer 23

21

Question 24

Skilled nursing facility

Answer 24

31

Question 25

Emergency room-hospital POS

Answer 25

23

Question 26

Consultation visits require a written report

Question 27

Observation status

Answer 27

Not required to be located in a designated area The patient is classified as ‘observation status’

Question 28

Encounter at hospital spans 2 calendar dates

Answer 28

It is a single service reported on one date

Question 29

Seen in another site of service, then admitted to hospital

Answer 29

The not hospital visit may be coded, use modifier 25 Other site can include nursing facility or ED

Question 30

Consultations performed on the same day in relation to an inpatient admission

Answer 30

Use subsequent hospital codes

Question 31

Prolonged service visits in the hospital/observation

Answer 31

99418

Question 32

Admit and discharge on one day

Answer 32

Requires a minimum of two encounters

Question 33

One encounter of the admit and discharge

Answer 33

Select code from the hospital inpatient/ observation initial visit codes

Question 34

Discharge codes

Answer 34

99238-99239 Used for physician/QHP responsible for discharging services based on duration of time spent discharging the patient

Question 35

Physician not responsible for discharge

Answer 35

Use subsequent hospital codes Hospital discharge when the patient has stayed overnight 99238-99239 For same day discharge use 99234-36

Question 36

Provider responsible for discharging the patient may use the discharge code, no one else

Question 37

Appropriate source for consultation

Answer 37

Physician, QHP, non-clinical social worker, educator, lawyer, insurance company

Question 38

Mandated consultation

Answer 38

Modifier 32

Question 39

3Rs Consultation

Answer 39

Appropriate source Recommendations Report back to requester

Question 40

Even as an initial consultation

Answer 40

Must be reported as subsequent visit if the consultant saw him prior to admission

Question 41

Office consultation and hospital consultation

Answer 41

Code office consultation then hospital consultation as subsequent visit

Question 42

All consultations are initial

Question 43

MDM

Answer 43

Diagnosis list Procedure list

Question 44

99252-99255

Answer 44

May be reported only once per consultant per admission of a patient who is in hospital inpatient or observation status

Question 45

ED Services

Answer 45

Hospital based, open 24 hours per day If critical care on same day as ED visit, code only CC If OBS status, admit and discharge on the same date, nursing facilities do not code ED Code separately reported E/M services Patients seen in the ED for the convenience of another physician/QHP code as office

Question 46

E/M

Answer 46

History/exam Location of the visit Type of visit: new/established Total time MDM E/M tables to select the code Apply all guidelines

Question 47

ED guidelines continued

Answer 47

Site of service might not solely determine the appropriate codes to report Reporting additional services or procedures with ED services are permitted, use the appropriate modifiers: 54, 55, 56, 59, etc