Chapter 17 - Evaluation & Management -
Review Questions
Musculoskeletal - ANS-Which system is given credit in the exam component when the provider
documents "range of motion, strength, and stability are adequate in both legs?"
The upper central region of the abdomen - ANS-When a patient complains of epigastric pain.
Where is the pain located?
99382-25, 90471, 90710 - ANS-A 2 year-old comes in for an initial WCE. Mom doesn't have the
child's immunization record. She states the child's last shot was when he was 5 months old.
Medical review and documentation of a new patient supports one element of HPI, five elements
of the ROS, and a complete PFSH. The examination was 8+ organ systems. The physician
orders the immunizations to be given in the office today. Immunizations given subcutaneously:
MMRV. What CPT codes are reported?
99214 - ANS-An established 45 year-old woman is seen today at her doctor's office. She is
complaining of being dizzy and feels like the room is spinning. She has had palpitations on and
off for the past 12 months. She reports chest tightness and dyspnea but denies nausea, edema,
or arm pain. She drinks two cups of coffee per day. Her sister has WPW
(Wolfe_Parkinson-White) syndrome. An extended five body area examination is performed. This
is a new problem for the physician. An EKG is ordered and labs are drawn, and physician
documents a moderate complexity MDM. What CPT® code is reported for this visit?
99238 - ANS-A 33 year-old white male was admitted to the hospital 12/17/16 from the ER,
following a motor vehicle accident, to have a splenectomy done. The patient is being discharged
from the hospital on 12/20/16. During his hospitalization, he was experiencing pain and
shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The physician
performed final examination and reviewed chest X-ray that revealed possible infiltrates and a
CT of the abdomen that ruled out any abscess. He was given a prescription of Zosyn. The
patient was told to follow up care with PCP or return back to the hospital for any pain or
bleeding. The physician spent 20 minutes. What CPT code is reported for the 12/20 visit?
99231 - ANS-The physician was notified to go to the hospital floor for medical management of a
56 year-old patient admitted one day ago for aspiration pneumonia and COPD. No chest pain at
present, but still SOB and some swelling in his lower extremities. He was tachypneic yesterday;
lungs reveal course crackles' in both bases, right worse than left. He is continuing with
intravenous antibiotic treatment and respiratory support, reviewed chest X-ray and labs. The
Review Questions
Musculoskeletal - ANS-Which system is given credit in the exam component when the provider
documents "range of motion, strength, and stability are adequate in both legs?"
The upper central region of the abdomen - ANS-When a patient complains of epigastric pain.
Where is the pain located?
99382-25, 90471, 90710 - ANS-A 2 year-old comes in for an initial WCE. Mom doesn't have the
child's immunization record. She states the child's last shot was when he was 5 months old.
Medical review and documentation of a new patient supports one element of HPI, five elements
of the ROS, and a complete PFSH. The examination was 8+ organ systems. The physician
orders the immunizations to be given in the office today. Immunizations given subcutaneously:
MMRV. What CPT codes are reported?
99214 - ANS-An established 45 year-old woman is seen today at her doctor's office. She is
complaining of being dizzy and feels like the room is spinning. She has had palpitations on and
off for the past 12 months. She reports chest tightness and dyspnea but denies nausea, edema,
or arm pain. She drinks two cups of coffee per day. Her sister has WPW
(Wolfe_Parkinson-White) syndrome. An extended five body area examination is performed. This
is a new problem for the physician. An EKG is ordered and labs are drawn, and physician
documents a moderate complexity MDM. What CPT® code is reported for this visit?
99238 - ANS-A 33 year-old white male was admitted to the hospital 12/17/16 from the ER,
following a motor vehicle accident, to have a splenectomy done. The patient is being discharged
from the hospital on 12/20/16. During his hospitalization, he was experiencing pain and
shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The physician
performed final examination and reviewed chest X-ray that revealed possible infiltrates and a
CT of the abdomen that ruled out any abscess. He was given a prescription of Zosyn. The
patient was told to follow up care with PCP or return back to the hospital for any pain or
bleeding. The physician spent 20 minutes. What CPT code is reported for the 12/20 visit?
99231 - ANS-The physician was notified to go to the hospital floor for medical management of a
56 year-old patient admitted one day ago for aspiration pneumonia and COPD. No chest pain at
present, but still SOB and some swelling in his lower extremities. He was tachypneic yesterday;
lungs reveal course crackles' in both bases, right worse than left. He is continuing with
intravenous antibiotic treatment and respiratory support, reviewed chest X-ray and labs. The
