Chapter 19: Evaluation and Management
1. Medical Abbreviations:
BP - Blood pressure
CC - Chief complaint
HEENT - Head, eyes, ears, nose, throat
h/o - History of
HPI - History of present illness
Hx - History
NAD - No apparent distress
NKDA - No known drug allergies
PE - Physical examination
PERRLA - Pupils equal, round, and reactive to light and accommodation (for
example, normal)
PMH - Past medical history
pt - Patient
R/O - Rule out
ROS - Review of systems
WNL - Within normal limits
2. Mr. Andrews, a 34-year-old male, visits Dr. Parker's office at the request
of Dr. Smith for a neurological consultation. He presents with complaints of
weakness, numbness, and pain in his left hand and arm. Dr. Parker
examines the patient and sends his recommendations and a written report
back to Dr. Smith for the care of the patient. Which category or subcategory
,of evaluation and management codes would be selected for the visit to Dr.
Parker?
A.Office visit, new patient
B.Office visit, established patient
C.Outpatient consultation
D.Case management services: RightAnswer: C. Outpatient consultation
Rationale: Dr. Smith requests Dr. Parker to see Mr. Andrews for a neurologic
consultation. Dr. Parker evaluates the patient and provides a written report to Dr.
Smith with a recommendation. The requirements for a consultation have been met
and an evaluation and management code from outpatient consultation would be
selected.
3. A mother takes her 2-year-old back to Dr. Denton for an annual well
child exam. The patient has a comprehensive checkup and vaccinations are
brought up to date. Which category or subcategory of evaluation and
management codes would be selected for the well child exam?
A.Office visit, established patient
B.Preventive medicine, established patient
C.Subsequent hospital care
D.Preventive medicine, individual counseling: RightAnswer:B. Preventive
medicine, established patient Rationale: The mother "takes her 2 year-old back to
Dr. Denton" indicates this is an established patient. This is a well child exam with
no complaints and a code from preventive medicine, established patient, would be
selected. The preventive medicine, individual counseling codes are used for risk
reduction such as diet and exercise, substance abuse, family problems, etc.
, 4. John, a 16-year-old male, is admitted by the emergency department
physician for observation after an ATV accident. The patient is discharged
from observation by another provider the next day. What category or
subcategory of evaluation and management codes would be selected for the
emergency department physician?
A.Office visit, new patient
B.Emergency department services
C.Initial hospital care
D.Initial observation care: RightAnswer:D. Initial observation care Rationale: The
patient presented to the Emergency Department and was admitted to observation
by the ED physician. The guidelines for Initial Observation Care state that all
services provided by the admitting physician for the same date of service are
included in the initial hospital care, and in this instance the emergency department
services would not be coded. If the patient was discharged on the same date of
service, a code from Observation or Inpatient Care Services (Including Admission
and Discharge Services) would be selected.
5. Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove
cancer from the spinal cord. He acted as a co-surgeon working with an
orthopedic surgeon. Dr. Hedrick followed up with the patient during his
rounds at the hospital the next day. From what category or subcategory of
evaluation and management services would Dr. Hedrick's follow-up visit be
reported?
A.Outpatient visit, established patient
B.Inpatient consultation
1. Medical Abbreviations:
BP - Blood pressure
CC - Chief complaint
HEENT - Head, eyes, ears, nose, throat
h/o - History of
HPI - History of present illness
Hx - History
NAD - No apparent distress
NKDA - No known drug allergies
PE - Physical examination
PERRLA - Pupils equal, round, and reactive to light and accommodation (for
example, normal)
PMH - Past medical history
pt - Patient
R/O - Rule out
ROS - Review of systems
WNL - Within normal limits
2. Mr. Andrews, a 34-year-old male, visits Dr. Parker's office at the request
of Dr. Smith for a neurological consultation. He presents with complaints of
weakness, numbness, and pain in his left hand and arm. Dr. Parker
examines the patient and sends his recommendations and a written report
back to Dr. Smith for the care of the patient. Which category or subcategory
,of evaluation and management codes would be selected for the visit to Dr.
Parker?
A.Office visit, new patient
B.Office visit, established patient
C.Outpatient consultation
D.Case management services: RightAnswer: C. Outpatient consultation
Rationale: Dr. Smith requests Dr. Parker to see Mr. Andrews for a neurologic
consultation. Dr. Parker evaluates the patient and provides a written report to Dr.
Smith with a recommendation. The requirements for a consultation have been met
and an evaluation and management code from outpatient consultation would be
selected.
3. A mother takes her 2-year-old back to Dr. Denton for an annual well
child exam. The patient has a comprehensive checkup and vaccinations are
brought up to date. Which category or subcategory of evaluation and
management codes would be selected for the well child exam?
A.Office visit, established patient
B.Preventive medicine, established patient
C.Subsequent hospital care
D.Preventive medicine, individual counseling: RightAnswer:B. Preventive
medicine, established patient Rationale: The mother "takes her 2 year-old back to
Dr. Denton" indicates this is an established patient. This is a well child exam with
no complaints and a code from preventive medicine, established patient, would be
selected. The preventive medicine, individual counseling codes are used for risk
reduction such as diet and exercise, substance abuse, family problems, etc.
, 4. John, a 16-year-old male, is admitted by the emergency department
physician for observation after an ATV accident. The patient is discharged
from observation by another provider the next day. What category or
subcategory of evaluation and management codes would be selected for the
emergency department physician?
A.Office visit, new patient
B.Emergency department services
C.Initial hospital care
D.Initial observation care: RightAnswer:D. Initial observation care Rationale: The
patient presented to the Emergency Department and was admitted to observation
by the ED physician. The guidelines for Initial Observation Care state that all
services provided by the admitting physician for the same date of service are
included in the initial hospital care, and in this instance the emergency department
services would not be coded. If the patient was discharged on the same date of
service, a code from Observation or Inpatient Care Services (Including Admission
and Discharge Services) would be selected.
5. Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove
cancer from the spinal cord. He acted as a co-surgeon working with an
orthopedic surgeon. Dr. Hedrick followed up with the patient during his
rounds at the hospital the next day. From what category or subcategory of
evaluation and management services would Dr. Hedrick's follow-up visit be
reported?
A.Outpatient visit, established patient
B.Inpatient consultation
