Test Bank for Primary Care Medicine
Office Evaluation and Management
of the Adult Patient 8th
Dr. X requests an orthopedist to take over the care of his patient with a new diagnosis of osteoporosis.
The orthopedist sees the patient on day 3 of admission. He performs a detailed history and detailed
exam. He evaluates the patient's newly diagnosed osteoporosis. He orders a bone density study and
prescribes Boniva for the patient. What CPT® code should be reported by the orthopedist?
a. 99221
b. 99233
c. 99253
d. 99232 - CORRECT ANSWERb. 99233
Medical review and documentation of an established patient supports three elements of HPI, two
elements of ROS, and a complete Past, Family, Social history. Also supported by the documentation is an
examination of eight body systems, one established stable diagnosis, and the physician's order for blood
tests. The physician documents a low complexity MDM. What CPT® code should be reported?
a. 99213
b. 99214
c. 99212
d. 99215 - CORRECT ANSWERa. 99213
A patient presents to the physician's office for the first time in two years with a cough and sore throat.
The physician suspects strep throat and does a brief history of the present illness, a problem pertinent
ROS and a detailed exam. The quick strep test results are negative and the medical decision making is of
low complexity. What are the appropriate E/M and ICD-9-CM codes for this service?
,a. 99212, 87880, 034.0
b. 99202, 86580, 462
c. 99213, 87880, 786.2, 462
d. 99204, 86580, 034.0 - CORRECT ANSWERc. 99213, 87880, 786.2, 462
A patient returns to the physician's office to see the nurse for a urine dip stick. The patient finished a
course of antibiotics for a UTI and the physician wants to check his urine to make sure the infection is
gone. The patient states he still sees blood in his urine. The nurse performs a U/A dip and the test comes
back positive. The patient is given another prescription for the UTI. The physician documents the
findings and signs off on the nurse's note. What procedure and diagnosis codes should be used?
a. 99212, 81002, 599.71, 788.41
b. 99211, 81002, 599.0
c. 99212, 81000, 599.70, 788.41, 599.0
d. 99211, 81000, 599.71, 788.41,599.0 - CORRECT ANSWERb. 99211, 81002, 599.0
Primary Care Provider: Dr Jones, Internal Medicine Physician Service Provided and Documented by: Dr
Smith, Internal Medicine Physician
Pt: Mary Jane Doe
DOS: 11-21-2008
Patient is a 26-year-old female in for one-month follow-up to our group practice for gastritis. My
partner, Dr. Jones, is unavailable today and this patient is new to me. She has no new complaint and no
recurrence of N&V (see previous note). Blood pressure 120/84, RRR, NBS, abdomen soft and non-
tender. All questions CORRECT ANSWERed. No scheduled flu. Return PRN. The MDM was
straightforward. What CPT® code should be reported?
a. 99201-26
b. 99202
c. 99211-26
d. 99212 - CORRECT ANSWERd. 99212
,A 28-day-old male child is brought into the emergency room in respiratory arrest with suspected SIDS.
The emergency room physician spends two hours plus thirty minutes resuscitating the child, using CPR,
and emergency endotracheal intubation, in order to stabilize his condition. How should the emergency
room physician code his services?
a. 99291, 99292 x 3, 92950, 31500
b. 99468, 92950
c. 99471
d. 99468, 92950, 31500 - CORRECT ANSWERd. 99468, 92950, 31500
65-year-old patient is brought into the ER in cardiac arrest. The emergency room physician spends 45
minutes with the critically ill patient. He uses defibrillation and emergency endotracheal intubation to
stabilize patient. The ER physician makes a notation that the 45 minutes does not include the time for
other separate billable services.How should the Emergency Room Physician code this service?
a. 99291-25, 92950, 31500
b. 99291-25, 92961, 31500
c. 92950, 31500
d. Medical record - CORRECT ANSWERContains health history, results of the physical examination,
laboratory reports, and progress notes.
Function of the medical record - CORRECT ANSWERTo provide information for making decisions
regarding the patient's care, to document the patient's progress, to serve as a legal document, and to
share information between members of the patient's family.
HIPAA Privacy Rule - CORRECT ANSWERProvides patients with more control over the use and disclosure
of their health information.
Patient registration record - CORRECT ANSWERIncludes demographic and billing information.
Demographic data for Medicare - CORRECT ANSWERIncludes ethnicity, current employer, and birth
place.
Subjective data about a patient - CORRECT ANSWERProvided by health history to assist the physician in
arriving at a diagnosis.
, Immunization record - CORRECT ANSWERIncludes name of the medication, route of administration,
dosage administered, manufacturer and lot number.
Consultation report - CORRECT ANSWERA narrative report of an opinion about a patient's condition by a
practitioner other than the attending physician.
Home health care services - CORRECT ANSWERIncludes IV therapy, respiratory care, rehabilitation, and
maternal-child care.
Diagnostic report - CORRECT ANSWERContains the results of the analysis of body specimens.
Report of a diagnostic procedure - CORRECT ANSWERExamples include urinalysis report, spirometry
report, colonoscopy report, and radiology report.
Physical therapy service - CORRECT ANSWERIncludes activities of daily living and hydrotherapy.
Occupational therapy - CORRECT ANSWERHelps a patient with a disability learn new ways to perform
skills such as dressing or cooking.
Inpatient - CORRECT ANSWERA patient who has been admitted to the hospital for at least one overnight
stay.
Medical impression - CORRECT ANSWERTerm used before there is enough information to make a
definitive diagnosis.
Operative report - CORRECT ANSWERDescribes a surgical procedure.
Discharge summary report - CORRECT ANSWERConsists of an account of the significant events of a
patient's hospitalization.
Office Evaluation and Management
of the Adult Patient 8th
Dr. X requests an orthopedist to take over the care of his patient with a new diagnosis of osteoporosis.
The orthopedist sees the patient on day 3 of admission. He performs a detailed history and detailed
exam. He evaluates the patient's newly diagnosed osteoporosis. He orders a bone density study and
prescribes Boniva for the patient. What CPT® code should be reported by the orthopedist?
a. 99221
b. 99233
c. 99253
d. 99232 - CORRECT ANSWERb. 99233
Medical review and documentation of an established patient supports three elements of HPI, two
elements of ROS, and a complete Past, Family, Social history. Also supported by the documentation is an
examination of eight body systems, one established stable diagnosis, and the physician's order for blood
tests. The physician documents a low complexity MDM. What CPT® code should be reported?
a. 99213
b. 99214
c. 99212
d. 99215 - CORRECT ANSWERa. 99213
A patient presents to the physician's office for the first time in two years with a cough and sore throat.
The physician suspects strep throat and does a brief history of the present illness, a problem pertinent
ROS and a detailed exam. The quick strep test results are negative and the medical decision making is of
low complexity. What are the appropriate E/M and ICD-9-CM codes for this service?
,a. 99212, 87880, 034.0
b. 99202, 86580, 462
c. 99213, 87880, 786.2, 462
d. 99204, 86580, 034.0 - CORRECT ANSWERc. 99213, 87880, 786.2, 462
A patient returns to the physician's office to see the nurse for a urine dip stick. The patient finished a
course of antibiotics for a UTI and the physician wants to check his urine to make sure the infection is
gone. The patient states he still sees blood in his urine. The nurse performs a U/A dip and the test comes
back positive. The patient is given another prescription for the UTI. The physician documents the
findings and signs off on the nurse's note. What procedure and diagnosis codes should be used?
a. 99212, 81002, 599.71, 788.41
b. 99211, 81002, 599.0
c. 99212, 81000, 599.70, 788.41, 599.0
d. 99211, 81000, 599.71, 788.41,599.0 - CORRECT ANSWERb. 99211, 81002, 599.0
Primary Care Provider: Dr Jones, Internal Medicine Physician Service Provided and Documented by: Dr
Smith, Internal Medicine Physician
Pt: Mary Jane Doe
DOS: 11-21-2008
Patient is a 26-year-old female in for one-month follow-up to our group practice for gastritis. My
partner, Dr. Jones, is unavailable today and this patient is new to me. She has no new complaint and no
recurrence of N&V (see previous note). Blood pressure 120/84, RRR, NBS, abdomen soft and non-
tender. All questions CORRECT ANSWERed. No scheduled flu. Return PRN. The MDM was
straightforward. What CPT® code should be reported?
a. 99201-26
b. 99202
c. 99211-26
d. 99212 - CORRECT ANSWERd. 99212
,A 28-day-old male child is brought into the emergency room in respiratory arrest with suspected SIDS.
The emergency room physician spends two hours plus thirty minutes resuscitating the child, using CPR,
and emergency endotracheal intubation, in order to stabilize his condition. How should the emergency
room physician code his services?
a. 99291, 99292 x 3, 92950, 31500
b. 99468, 92950
c. 99471
d. 99468, 92950, 31500 - CORRECT ANSWERd. 99468, 92950, 31500
65-year-old patient is brought into the ER in cardiac arrest. The emergency room physician spends 45
minutes with the critically ill patient. He uses defibrillation and emergency endotracheal intubation to
stabilize patient. The ER physician makes a notation that the 45 minutes does not include the time for
other separate billable services.How should the Emergency Room Physician code this service?
a. 99291-25, 92950, 31500
b. 99291-25, 92961, 31500
c. 92950, 31500
d. Medical record - CORRECT ANSWERContains health history, results of the physical examination,
laboratory reports, and progress notes.
Function of the medical record - CORRECT ANSWERTo provide information for making decisions
regarding the patient's care, to document the patient's progress, to serve as a legal document, and to
share information between members of the patient's family.
HIPAA Privacy Rule - CORRECT ANSWERProvides patients with more control over the use and disclosure
of their health information.
Patient registration record - CORRECT ANSWERIncludes demographic and billing information.
Demographic data for Medicare - CORRECT ANSWERIncludes ethnicity, current employer, and birth
place.
Subjective data about a patient - CORRECT ANSWERProvided by health history to assist the physician in
arriving at a diagnosis.
, Immunization record - CORRECT ANSWERIncludes name of the medication, route of administration,
dosage administered, manufacturer and lot number.
Consultation report - CORRECT ANSWERA narrative report of an opinion about a patient's condition by a
practitioner other than the attending physician.
Home health care services - CORRECT ANSWERIncludes IV therapy, respiratory care, rehabilitation, and
maternal-child care.
Diagnostic report - CORRECT ANSWERContains the results of the analysis of body specimens.
Report of a diagnostic procedure - CORRECT ANSWERExamples include urinalysis report, spirometry
report, colonoscopy report, and radiology report.
Physical therapy service - CORRECT ANSWERIncludes activities of daily living and hydrotherapy.
Occupational therapy - CORRECT ANSWERHelps a patient with a disability learn new ways to perform
skills such as dressing or cooking.
Inpatient - CORRECT ANSWERA patient who has been admitted to the hospital for at least one overnight
stay.
Medical impression - CORRECT ANSWERTerm used before there is enough information to make a
definitive diagnosis.
Operative report - CORRECT ANSWERDescribes a surgical procedure.
Discharge summary report - CORRECT ANSWERConsists of an account of the significant events of a
patient's hospitalization.
