Question

CPT CODING Evaluation and Management Coding


1. A new patient is seen in the office for otalgia. The history is problem focused, the examination is problem focused, and the medical decision-making complexity is straightforward.

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2. An established patient is seen in the office for otalgia. The history and exam is expanded problem focused and the medical decision-making component is straightforward.

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3. An established patient is seen in the office for suture removal that is done by the physician’s nurse.

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4. A new patient is seen in the office for a comprehensive examination that requires a comprehensive history and high complexity of medical decision making.

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5. A new patient is seen in the office with pneumonia. The physician performs a detailed history and detailed physical examination. Medical decision making is of moderate complexity.

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6. A new patient is admitted to the hospital on an observation status after a fall of moderate severity. The physician provided a comprehensive history and physical examination. The medical decision making was recorded in the patient’s chart as moderate in complexity.

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7. A patient is admitted to the hospital by the physician for pneumonia. The initial hospital care is comprehensive history and examination, with medical decision making of low complexity. The time spent is approximately 30 minutes.

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8. The physician calls in a consultant for an inpatient. The consultant does a problem- focused history and physical examination. Decision-making is straightforward.

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9. A new patient in a nursing home is visited by the physician. The history is detailed and the physical examination is comprehensive. The medical decision-making is straightforward.

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10. Lilly Wilson, a new patient, was seen by the physician in the nursing home for an initial visit for admission to the nursing facility. The history and physical were comprehensive. The level of medical decision-making was moderate.

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11. Jeff Johnson, an established patient, is seen in the hospital on a subsequent visit. The physician did a detailed interval history and physical examination. The medical decision-making was of high complexity.

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12. John Taylor is a 16-year-old outpatient who is a new patient to your office. John complains of severe acne. The history is expanded problem-focused with an expanded problem-focused physical examination. The medical decision making is straightforward. The physician spends approximately 20 minutes with the patient.

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13. Jan Sharp, an established patient, had an office appointment because she needed a new dressing on the laceration on her arm. The physician’s nurse changed the dressing.

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14. Gladys Swain was seen in the emergency department of the hospital with the complaint of a sprained ankle. The history and physical examination are problem focused. There are no complications, and the medical decision making was straightforward.

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15. Anne Rall was seen in the emergency department for a rapid heart rate. History and exam were not able to be performed in a comprehensive manner as the patient was in a very anxious state. The presenting problem was very significant. The medical decision- making was high.

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16. The physician was called to the intensive care unit at the hospital to care for Joe West, a patient in coronary crisis. The physician spent an hour at the patient’s bedside stabilizing him.

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17. The physician was preparing to leave the hospital after he saw Joe West, but was called back to the intensive care unit to see and stabilize another patient, Ted Keel. The service to Mr. Keel took one and one-half hours.

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18. George White, an established patient, needed to be seen at his home for follow-up care after surgery. George is improving but is in a wheelchair and his wife doesn’t drive. The physician did a problem-focused physical examination and problem-focused interval history. Decision-making was of low complexity.

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19. Henry Green, an established patient, came into the office for his yearly physical examination. Henry is 72 and in good health.

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20. An established patient, Harriet Turner, came into the office for a visit because her medication for depression was making her lethargic. The physician saw Harriet for 25 minutes, during which time a detailed history and physical examination were done. The medical decision-making was of moderate complexity.

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21. Dr. Wellton called your office and asked the physician to do a consultation on Carol Jones for advice on the management of her diabetes. Carol is an inpatient at the local hospital, who had surgery last week, but is not making satisfactory progress on her recovery. The history and physical examination were comprehensive and medical decision making was of a moderate complexity.

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22. The physician provided subsequent services to a critically ill but stable newborn in the neonatal intensive care unit. The infant required cardiopulmonary monitoring and support.

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Answer 1

Answer:

1. 99201 - Problem focused history ,problem focused examination and straightforward decision making.

2. 99202 - Expanded problem focused history and examination, straightforward decision making.

3. 99211 - Suture removal done by physician's nurse

4. 99205 - Comprehensive history and examination, high complexity of decision making .