E/M Review With complete solution
Newest 2024/25
Dr. X asks Dr. Y to look at a 55 year-old male who is in a nursing facility for decubitus
l l l l l l l l l l l l l l l l l l l
ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a
l l l l l l l l l l l l l l l l
detailed history from Dr. X since the patient is unable to provide a history. A detailed exam
l l l l l l l l l l l l l l l l l
along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to
l l l l l l l l l l l l l l l l l l l
the surgical suite for debridement of the ulcerations. Since the patient is unstable at the
l l l l l l l l l l l l l l l
moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep
l l l l l l l l l l l l l l l l l
monitoring the patient until he stabilizes. Written report is documented. What CPT® code is
l l l l l l l l l l l l l l
reported? - Correct Answers 99253
l l ll l llll
Rationale: Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing facility.
l l l l l l l l l l l l l l l l l
According to CPT® guidelines: "The initial inpatient consultation codes (99251-99255), are
l l l l l l l l l l l
to be used only once by the reporting provider for an individual hospital or nursing facility
l l l l l l l l l l l l l l l l
patient for a particular admission. These codes are to be reported for consultations provided
l l l l l l l l l l l l l l
to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting." A
l l l l l l l l l l l l l l l
consultation is a type of service provided by a provider whose opinion or advice regarding
l l l l l l l l l l l l l l l
evaluation and /or management of a specific problem is requested by another provider. The
l l l l l l l l l l l l l l
consulting provider performs the consultation, documents his or her opinion in the patient's
l l l l l l l l l l l l l
medical record, and communicates findings/recommendations by written report to the
l l l l l l l l l l
requesting provider or other appropriate source. Consultations require the documentation
l l l l l l l l l l
of three of three key components. The provider performed a detailed history, detailed exam
l l l l l l l l l l l l l l
and moderate MDM. The correct code is 99253.
l l l l l l l l
Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal
l l l l l l l l l l l l l l
l pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the l l l l l l l l l l l l l l l
l medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley l l l l l l l l l l l l l l
l Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home
l l l l l l l l l l l l l l
l after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She
l l l l l l l l l l l l l l l
l obtains a detailed interval history, does comprehensive examination and the medical
l l l l l l l l l l
l decision making is moderate complexity. What is/are the appropriate evaluation and
l l l l l l l l l l
l management code(s) for this visit? - Correct Answers 99239, 99304 l l l l l ll l llll l
Rationale: Hospital discharge is a time-based code. The documentation states that the
l l l l l l l l l l l
provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital
l l l l l l l l l l l l l l
Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the
l l l l l l l l l l l l l
patient was readmitted to a skilled nursing facility (SNF) where he is a resident. CPT®
l l l l l l l l l l l l l l l
guidelines preceding the Initial Nursing Facility Care codes state when a patient is
l l l l l l l l l l l l l
discharged from the hospital on the same day and readmitted to a nursing facility both the
l l l l l l l l l l l l l l l l
discharge and readmission is reported. Initial nursing facility care codes require the three
l l l l l l l l l l l l l
key components to meet or exceed the requirements. Documentation tells us the physician
l l l l l l l l l l l l l
provided a detailed history, comprehensive exam, and medical decision making was of
l l l l l l l l l l l l
moderate complexity. Code 99304 states the history and exam can be detailed or
l l l l l l l l l l l l l
, l comprehensive. Our documentation shows it to be of moderate complexity, which meets the l l l l l l l l l l l l
l requirements. Because our history is only detailed, the requirements are not met for 99305. l l l l l l l l l l l l l
An established patient presents to the office with a recurrence of bursitis in both shoulders.
l l l l l l l l l l l l l l l
l Examination is limited only to the shoulders in which range of motion is good and full, but he l l l l l l l l l l l l l l l l l
l has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa
l l l l l l l l l l l l l
l with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit? - Correct
l l l l l l l l l l l ll
l Answers 20610-50 llll
Rationale: For this encounter, no additional work in evaluating the patient has been l l l l l l l l l l l l
performed to support an E/M service that is significant and separately identifiable from the
l l l l l l l l l l l l l l
procedure. Only the procedure is billed. To perform an arthrocentesis, the physician inserts
l l l l l l l l l l l l l
a needle through the skin and into a joint or bursa. A fluid sample may be removed from the
l l l l l l l l l l l l l l l l l l l
joint or fluid may be injected for lavage or drug therapy. In the CPT® Index look for
l l l l l l l l l l l l l l l l l
Shoulder/Arthrocentesis. You are referred to codes 20610 and 20611. Review the code
l l l l l l l l l l l l
description to verify accuracy. Modifier 50 Bilateral Procedure is attached since both
l l l l l l l l l l l l
shoulders are injected. CPT ® code 20611 is not correct because it includes ultrasound
l l l l l l l l l l l l l l
guidance with permanent recording and reporting.
l l l l l l
A 60 year-old woman is seeking help to quit smoking. She makes an appointment to see Dr.
l l l l l l l l l l l l l l l l l
l Lung for an initial visit. The patient has a constant cough due to smoking and some shortness
l l l l l l l l l l l l l l l l
l of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has
l l l l l l l l l l l l l l
l tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years
l l l l l l l l l l l l l l l
l and smokes 2 packs per day. She has a family history of emphysema. A limited three system
l l l l l l l l l l l l l l l l
l exam was performed. Dr Lung discussed in detail the pros and cons of medications used to
l l l l l l l l l l l l l l l
l quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit.
l l l l l l l l l l l l l l
l Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A l l l l l l l l l l l l l l l
l chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this
l l l l l l l l l l l l l l
l visit. - Correct Answers 99203 l ll l llll
Rationale: Patient is coming to the provider's office for help to quit smoking. The patient is l l l l l l l l l l l l l l l
new. The provider documents that 20 minutes of the 30 minute visit was spent counseling
l l l l l l l l l l l l l l l
the patient. E/M Guidelines identify when time is considered the key or controlling factor to
l l l l l l l l l l l l l l l
qualify for an E/M service. When counseling and/or coordination of care is more than 50%
l l l l l l l l l l l l l l l
face to face time in the office or other outpatient setting, time may be used to determine the
l l l l l l l l l l l l l l l l l l
level of E/M. The correct code is 99203 based on the total time of the visit which is 30 minutes.
l l l l l l l l l l l l l l l l l l l l
ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and
l l l l l l l l l l l l
l sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been l l l l l l l l l l
l running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has
l l l l l l l l l l l l
l worsened, but patient remains non-oliguric. PHYSICAL EXAM: BP 96/60, Pulse 112, Temp l l l l l l l l l l l
l 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive
l l l l l l l l l l l l l l
l bowel sounds. Extremities show moderate edema. LABS: BUN 89, creatinine 2.6, HGB
l l l l l l l l l l l
l 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.
l l l l l l l l l l l
l IMPRESSION Hypoxic respiratory failure Community acquired pneumonia Septic shock l l l l l l l l
l Non-oliguric acute renal failure PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 l l l l l l l l l l l l l
Newest 2024/25
Dr. X asks Dr. Y to look at a 55 year-old male who is in a nursing facility for decubitus
l l l l l l l l l l l l l l l l l l l
ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a
l l l l l l l l l l l l l l l l
detailed history from Dr. X since the patient is unable to provide a history. A detailed exam
l l l l l l l l l l l l l l l l l
along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to
l l l l l l l l l l l l l l l l l l l
the surgical suite for debridement of the ulcerations. Since the patient is unstable at the
l l l l l l l l l l l l l l l
moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep
l l l l l l l l l l l l l l l l l
monitoring the patient until he stabilizes. Written report is documented. What CPT® code is
l l l l l l l l l l l l l l
reported? - Correct Answers 99253
l l ll l llll
Rationale: Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing facility.
l l l l l l l l l l l l l l l l l
According to CPT® guidelines: "The initial inpatient consultation codes (99251-99255), are
l l l l l l l l l l l
to be used only once by the reporting provider for an individual hospital or nursing facility
l l l l l l l l l l l l l l l l
patient for a particular admission. These codes are to be reported for consultations provided
l l l l l l l l l l l l l l
to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting." A
l l l l l l l l l l l l l l l
consultation is a type of service provided by a provider whose opinion or advice regarding
l l l l l l l l l l l l l l l
evaluation and /or management of a specific problem is requested by another provider. The
l l l l l l l l l l l l l l
consulting provider performs the consultation, documents his or her opinion in the patient's
l l l l l l l l l l l l l
medical record, and communicates findings/recommendations by written report to the
l l l l l l l l l l
requesting provider or other appropriate source. Consultations require the documentation
l l l l l l l l l l
of three of three key components. The provider performed a detailed history, detailed exam
l l l l l l l l l l l l l l
and moderate MDM. The correct code is 99253.
l l l l l l l l
Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal
l l l l l l l l l l l l l l
l pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the l l l l l l l l l l l l l l l
l medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley l l l l l l l l l l l l l l
l Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home
l l l l l l l l l l l l l l
l after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She
l l l l l l l l l l l l l l l
l obtains a detailed interval history, does comprehensive examination and the medical
l l l l l l l l l l
l decision making is moderate complexity. What is/are the appropriate evaluation and
l l l l l l l l l l
l management code(s) for this visit? - Correct Answers 99239, 99304 l l l l l ll l llll l
Rationale: Hospital discharge is a time-based code. The documentation states that the
l l l l l l l l l l l
provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital
l l l l l l l l l l l l l l
Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the
l l l l l l l l l l l l l
patient was readmitted to a skilled nursing facility (SNF) where he is a resident. CPT®
l l l l l l l l l l l l l l l
guidelines preceding the Initial Nursing Facility Care codes state when a patient is
l l l l l l l l l l l l l
discharged from the hospital on the same day and readmitted to a nursing facility both the
l l l l l l l l l l l l l l l l
discharge and readmission is reported. Initial nursing facility care codes require the three
l l l l l l l l l l l l l
key components to meet or exceed the requirements. Documentation tells us the physician
l l l l l l l l l l l l l
provided a detailed history, comprehensive exam, and medical decision making was of
l l l l l l l l l l l l
moderate complexity. Code 99304 states the history and exam can be detailed or
l l l l l l l l l l l l l
, l comprehensive. Our documentation shows it to be of moderate complexity, which meets the l l l l l l l l l l l l
l requirements. Because our history is only detailed, the requirements are not met for 99305. l l l l l l l l l l l l l
An established patient presents to the office with a recurrence of bursitis in both shoulders.
l l l l l l l l l l l l l l l
l Examination is limited only to the shoulders in which range of motion is good and full, but he l l l l l l l l l l l l l l l l l
l has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa
l l l l l l l l l l l l l
l with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit? - Correct
l l l l l l l l l l l ll
l Answers 20610-50 llll
Rationale: For this encounter, no additional work in evaluating the patient has been l l l l l l l l l l l l
performed to support an E/M service that is significant and separately identifiable from the
l l l l l l l l l l l l l l
procedure. Only the procedure is billed. To perform an arthrocentesis, the physician inserts
l l l l l l l l l l l l l
a needle through the skin and into a joint or bursa. A fluid sample may be removed from the
l l l l l l l l l l l l l l l l l l l
joint or fluid may be injected for lavage or drug therapy. In the CPT® Index look for
l l l l l l l l l l l l l l l l l
Shoulder/Arthrocentesis. You are referred to codes 20610 and 20611. Review the code
l l l l l l l l l l l l
description to verify accuracy. Modifier 50 Bilateral Procedure is attached since both
l l l l l l l l l l l l
shoulders are injected. CPT ® code 20611 is not correct because it includes ultrasound
l l l l l l l l l l l l l l
guidance with permanent recording and reporting.
l l l l l l
A 60 year-old woman is seeking help to quit smoking. She makes an appointment to see Dr.
l l l l l l l l l l l l l l l l l
l Lung for an initial visit. The patient has a constant cough due to smoking and some shortness
l l l l l l l l l l l l l l l l
l of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has
l l l l l l l l l l l l l l
l tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years
l l l l l l l l l l l l l l l
l and smokes 2 packs per day. She has a family history of emphysema. A limited three system
l l l l l l l l l l l l l l l l
l exam was performed. Dr Lung discussed in detail the pros and cons of medications used to
l l l l l l l l l l l l l l l
l quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit.
l l l l l l l l l l l l l l
l Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A l l l l l l l l l l l l l l l
l chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this
l l l l l l l l l l l l l l
l visit. - Correct Answers 99203 l ll l llll
Rationale: Patient is coming to the provider's office for help to quit smoking. The patient is l l l l l l l l l l l l l l l
new. The provider documents that 20 minutes of the 30 minute visit was spent counseling
l l l l l l l l l l l l l l l
the patient. E/M Guidelines identify when time is considered the key or controlling factor to
l l l l l l l l l l l l l l l
qualify for an E/M service. When counseling and/or coordination of care is more than 50%
l l l l l l l l l l l l l l l
face to face time in the office or other outpatient setting, time may be used to determine the
l l l l l l l l l l l l l l l l l l
level of E/M. The correct code is 99203 based on the total time of the visit which is 30 minutes.
l l l l l l l l l l l l l l l l l l l l
ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and
l l l l l l l l l l l l
l sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been l l l l l l l l l l
l running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has
l l l l l l l l l l l l
l worsened, but patient remains non-oliguric. PHYSICAL EXAM: BP 96/60, Pulse 112, Temp l l l l l l l l l l l
l 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive
l l l l l l l l l l l l l l
l bowel sounds. Extremities show moderate edema. LABS: BUN 89, creatinine 2.6, HGB
l l l l l l l l l l l
l 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.
l l l l l l l l l l l
l IMPRESSION Hypoxic respiratory failure Community acquired pneumonia Septic shock l l l l l l l l
l Non-oliguric acute renal failure PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 l l l l l l l l l l l l l
