E/M Review Grade A fully answered questions and
Dr. X asks Dr. Y to look at a 55 year-old male who is in a nursing facility for decubitus
ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a
detailed history from Dr. X since the patient is unable to provide a history. A detailed
exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient
needs to go to the surgical suite for debridement of the ulcerations. Since the patient is
unstable at the moment due to elevated blood pressure and a UTI, they decide to delay
surgery and to keep monitoring the patient until he stabilizes. Written report is
documented. What CPT® code is reported? - (correct answer)99253
Rationale: Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing
facility. According to CPT® guidelines: "The initial inpatient consultation codes (99251-
99255), are to be used only once by the reporting provider for an individual hospital or
nursing facility patient for a particular admission. These codes are to be reported for
consultations provided to hospital inpatients, residents of nursing facilities, or patients in
a partial hospital setting." A consultation is a type of service provided by a provider
whose opinion or advice regarding evaluation and /or management of a specific
problem is requested by another provider. The consulting provider performs the
consultation, documents his or her opinion in the patient's medical record, and
communicates findings/recommendations by written report to the requesting provider or
other appropriate source. Consultations require the documentation of three of three key
components. The provider performed a detailed history, detailed exam and moderate
MDM. The correct code is 99253.
Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of
pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr.
Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a
resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease
and will return to the nursing home after discharge. On the same day Dr. Inez re-admits
Mr. Blancos to the nursing facility. She obtains a detailed interval history, does
comprehensive examination and the medical decision making is moderate complexity.
What is/are the appropriate evaluation and management code(s) for this visit? - (correct
answer)99239, 99304
, Rationale: Hospital discharge is a time-based code. The documentation states that the
provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital
Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge
the patient was readmitted to a skilled nursing facility (SNF) where he is a resident.
CPT® guidelines preceding the Initial Nursing Facility Care codes state when a patient
is discharged from the hospital on the same day and readmitted to a nursing facility both
the discharge and readmission is reported. Initial nursing facility care codes require the
three key components to meet or exceed the requirements. Documentation tells us the
physician provided a detailed history, comprehensive exam, and medical decision
making was of moderate complexity. Code 99304 states the history and exam can be
detailed or comprehensive. Our documentation shows it to be of moderate complexity,
which meets the requirements. Because our history is only detailed, the requirements
are not met for 99305.
An established patient presents to the office with a recurrence of bursitis in both
shoulders. Examination is limited only to the shoulders in which range of motion is good
and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in
the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this
visit? - (correct answer)20610-50
Rationale: For this encounter, no additional work in evaluating the patient has been
performed to support an E/M service that is significant and separately identifiable from
the procedure. Only the procedure is billed. To perform an arthrocentesis, the physician
inserts a needle through the skin and into a joint or bursa. A fluid sample may be
removed from the joint or fluid may be injected for lavage or drug therapy. In the CPT®
Index look for Shoulder/Arthrocentesis. You are referred to codes 20610 and 20611.
Review the code description to verify accuracy. Modifier 50 Bilateral Procedure is
attached since both shoulders are injected. CPT ® code 20611 is not correct because it
includes ultrasound guidance with permanent recording and reporting.
A 60 year-old woman is seeking help to quit smoking. She makes an appointment to
see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and
some shortness of breath. No night sweats, weight loss, night fever, CP, headache or
dizziness. She has tried patches and nicotine gum which has not helped. Patient has
been smoking for 40 years and smokes 2 packs per day. She has a family history of
emphysema. A limited three system exam was performed. Dr Lung discussed in detail
the pros and cons of medications used to quit smoking. Counseling and education was
Dr. X asks Dr. Y to look at a 55 year-old male who is in a nursing facility for decubitus
ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a
detailed history from Dr. X since the patient is unable to provide a history. A detailed
exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient
needs to go to the surgical suite for debridement of the ulcerations. Since the patient is
unstable at the moment due to elevated blood pressure and a UTI, they decide to delay
surgery and to keep monitoring the patient until he stabilizes. Written report is
documented. What CPT® code is reported? - (correct answer)99253
Rationale: Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing
facility. According to CPT® guidelines: "The initial inpatient consultation codes (99251-
99255), are to be used only once by the reporting provider for an individual hospital or
nursing facility patient for a particular admission. These codes are to be reported for
consultations provided to hospital inpatients, residents of nursing facilities, or patients in
a partial hospital setting." A consultation is a type of service provided by a provider
whose opinion or advice regarding evaluation and /or management of a specific
problem is requested by another provider. The consulting provider performs the
consultation, documents his or her opinion in the patient's medical record, and
communicates findings/recommendations by written report to the requesting provider or
other appropriate source. Consultations require the documentation of three of three key
components. The provider performed a detailed history, detailed exam and moderate
MDM. The correct code is 99253.
Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of
pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr.
Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a
resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease
and will return to the nursing home after discharge. On the same day Dr. Inez re-admits
Mr. Blancos to the nursing facility. She obtains a detailed interval history, does
comprehensive examination and the medical decision making is moderate complexity.
What is/are the appropriate evaluation and management code(s) for this visit? - (correct
answer)99239, 99304
, Rationale: Hospital discharge is a time-based code. The documentation states that the
provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital
Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge
the patient was readmitted to a skilled nursing facility (SNF) where he is a resident.
CPT® guidelines preceding the Initial Nursing Facility Care codes state when a patient
is discharged from the hospital on the same day and readmitted to a nursing facility both
the discharge and readmission is reported. Initial nursing facility care codes require the
three key components to meet or exceed the requirements. Documentation tells us the
physician provided a detailed history, comprehensive exam, and medical decision
making was of moderate complexity. Code 99304 states the history and exam can be
detailed or comprehensive. Our documentation shows it to be of moderate complexity,
which meets the requirements. Because our history is only detailed, the requirements
are not met for 99305.
An established patient presents to the office with a recurrence of bursitis in both
shoulders. Examination is limited only to the shoulders in which range of motion is good
and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in
the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this
visit? - (correct answer)20610-50
Rationale: For this encounter, no additional work in evaluating the patient has been
performed to support an E/M service that is significant and separately identifiable from
the procedure. Only the procedure is billed. To perform an arthrocentesis, the physician
inserts a needle through the skin and into a joint or bursa. A fluid sample may be
removed from the joint or fluid may be injected for lavage or drug therapy. In the CPT®
Index look for Shoulder/Arthrocentesis. You are referred to codes 20610 and 20611.
Review the code description to verify accuracy. Modifier 50 Bilateral Procedure is
attached since both shoulders are injected. CPT ® code 20611 is not correct because it
includes ultrasound guidance with permanent recording and reporting.
A 60 year-old woman is seeking help to quit smoking. She makes an appointment to
see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and
some shortness of breath. No night sweats, weight loss, night fever, CP, headache or
dizziness. She has tried patches and nicotine gum which has not helped. Patient has
been smoking for 40 years and smokes 2 packs per day. She has a family history of
emphysema. A limited three system exam was performed. Dr Lung discussed in detail
the pros and cons of medications used to quit smoking. Counseling and education was
